Mental health consumer perspectives of a person-centred multidisciplinary care planning meeting on a rehabilitation inpatient unit

Mental health consumers are seeking genuine involvement in the planning regarding their treatment and care; however for many consumers in inpatient mental health settings, there is not the opportunity to participate. Current research evaluating person-centred multidisciplinary care planning initiatives in inpatient settings from the consumer perspective is limited. The aim of this study was to explore the consumer perspective of a person-centred multidisciplinary care planning meeting implemented in an Australian inpatient mental health rehabilitation unit. This study used a focused ethnographic design with data collection including fieldnotes, observations of meetings and interviews. Ten individuals participated in the study, with two participating in meeting observations and eight participating in structured interviews. Participants were consumers with a mental health diagnosis admitted to a mental health rehabilitation unit for assistance with achieving their goals for community living. Findings were analysed utilizing thematic analysis. Findings showed that consumers' experiences of the care planning meetings were positive. Themes included; ‘It's about you’, ‘Making decisions and expressing opinions’, ‘Staff involvement in care planning’ and ‘Supporting consumer recovery’. These findings add the consumer perspective to the existing evidence base and support the implementation of person-centred multidisciplinary care planning meetings in inpatient mental health settings.     

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.     

The impact of workplace culture on the accountability of mental health nurses to involve consumers in care planning: A focused ethnography

Recovery‐oriented mental health practice guidelines recommend regular consumer involvement in care plans, yet in many acute settings, these are not routinely created thereby compromising accountability. This study explored the impact of workplace culture on the capacity of mental health nurses to involve consumers in care planning and consequently to work accountably. A focused ethnography was undertaken in one Australian inpatient unit involving mental health nurses and other health professionals. Data were derived from in‐depth semistructured interviews with 12 nurses and 6 months of nonparticipant observation of multidisciplinary meetings and clinical handovers. Workplace culture had an impact on mental health nurses' accountability practices. A culture that prioritized reduction in length of stay resulted in less recovery‐oriented care. Health professionals who paid more attention to crisis and risk management resulted in fewer opportunities for consumer‐involved care planning.     

The challenges of mental health care reform for contemporary mental health nursing practice: delivery of nursing care

This ethnographic account of mental health nursing in a 22-bed acute inpatient facility in New South Wales, Australia, uncovered cultural meaning and cultural realities associated with the delivery of nursing care within the context of current challenges, demands, and influences brought about by service reforms. The findings demonstrate that mental health nurses have been responsive to changes brought about by the reforms. The ability of nurses to readily identify service gaps in their everyday practice provides them with the opportunity to develop strategies to respond to workplace challenges. As such, findings of the study contribute to current discussions concerning acute inpatient mental health nursing practice.     

The realities of mental health nursing in acute inpatient environments

ABSTRACT:  The purpose of this ethnographic study was to understand how nurses construct their practice in an acute inpatient psychiatric unit in light of the current challenges, demands and influences brought about by service reform. During a 5-month period, fieldwork observations, interviews and discussion groups occurred in a 22-bed acute inpatient mental health facility in New South Wales, Australia. The findings demonstrate how the current role of acute care has resulted in nurses working in increasingly complex environments characterized by competing priorities and new demands. Nurses struggled to fit the changed service philosophy with traditional models of practice within this fluid and changing environment. The findings are relevant within the context of current debates and can be used to enhance the understanding of contemporary acute mental health nursing practice and inform the continued development of mental health nursing in these settings.     

Attitudes of postgraduate nursing students towards consumer participation in mental health services and the role of the consumer academic

Consumer participation in health care is increasingly becoming an expectation of health services. While important progress has been made in the mental health area, the attitudes of mental health professionals towards consumers poses a severe limitation. Greater consumer involvement in the education of mental health professionals has been presented as a strategy to encourage the development of a greater acceptance of consumer involvement by health professionals. A consumer academic position has been introduced into the Centre for Psychiatric Nursing Research and Practice. An important aspect of this role concerns the education of postgraduate psychiatric/mental health nursing students, in order to provide a consumer perspective and encourage greater consumer participation. In order to determine the impact of this project a questionnaire was developed by the authors to measure attitudes to consumer participation and the role of the consumer academic. This paper presents the first stage of this study. The questionnaire was administered to students (n = 25) on the first day of the course. The findings suggest that most students favour a high level of consumer participation but that this is limited to specific areas of treatment planning and delivery. Furthermore, the students' demonstrate some level of ambivalence regarding the value and necessity of the consumer academic role.     

Triumph and adversity: Exploring the complexities of consumer storytelling in mental health nursing education

Consumer participation in the education of health professionals is increasing, particularly in mental health nursing education and storytelling remains the most frequent approach to consumer involvement. The use of story has tended to be accepted as a legitimate educational tool with limited critique or consideration of its potential consequences presented within the academic literature. A qualitative exploratory research study was undertaken with mental health nurse academics (n = 34) and consumer educators and academics (n = 12), to investigate the perceptions and experiences of mental health nurses and consumers regarding the involvement of consumers in mental health nursing education. Data were analysed thematically. Story was a major theme to emerge from consumer participants and received some attention from nurse academics. Consumers and nurses both referred to the power of story to convey the human experience of mental illness diagnosis and service use; and the vulnerability that can result from storytelling. Consumers also described: story as expectation; preparation and support; and the politics of story. All participants supported the value of storytelling in mental health nursing education. Consumers had considered the complexities in far greater detail. The ongoing value of story as an educational technique requires further research. Equally important is considering a broader range of educational roles for mental health consumers.     

Therapeutic engagement between consumers in suicidal crisis and mental health nurses

Registered nurses within public mental health services play crucial roles in helping people recover from suicidal crisis. However, there is a lack of understanding of how care is experienced in this context, and available evidence suggests that nurses and consumers are often dissatisfied with the quality of care. There is thus an imperative to generate understanding of needs and experiences of both groups with a view to informing practice development. This article summarizes qualitative findings from a multimethod study undertaken in Australia, which surveyed and interviewed mental health nurses who had recent experience of caring for consumers in suicidal crisis in a hospital setting, and interviewed consumers who had recovered from a recent suicidal crisis. A framework was developed to guide the study and support ethical imperatives; in particular, the promotion of consumer well‐being. The findings highlight that therapeutic interpersonal engagement between nurses and consumers was central to quality care. This was particularly noted, as engagement could help reduce consumer isolation, loss of control, distress, and objectification of the delivery of potentially‐objectifying common interventions. Of concern, the results indicate a lack of therapeutic engagement from the perspective of both consumers and nurses. Recommendations to promote fuller therapeutic engagement are presented.     

Authentic engagement: A conceptual model for welcoming diverse and challenging consumer and survivor views in mental health research,policy, and practice

As involvement of consumers/survivors in planning, delivery, and evaluation of services has increased, expectations of authentic and effective engagement, versus tokenism, have also risen. Different factors contribute to, or detract from, authentic engagement. Writing from mental health consumer/survivor and nursing positioning, respectively, we aim to redress the common problem of including only a narrow range of views and voices. This paper introduces a conceptual model that supports leaders in research, clinical, service, and policy roles to understand the necessity of engaging with a broader spectrum of consumer/survivor views and voices. The model draws on published consumer/survivor materials, making explicit diverse experiences of treatment and care and identifying the subsequent rich consumer/survivor advocacy agendas. We propose that strong co‐production is made possible by recognizing and welcoming consumer/survivor activist, facilitator, transformer, and humanizer contributions. The conceptual model forms the basis for a proposed qualitative validation project.     

Understanding consumer participation in mental health: Issues of power and change

Consumer participation occurs in all Victorian public mental health services. Area mental health services employ consumer consultants to enhance consumer participation across the network. Ongoing support of management is essential to the success of consumer participation. This project aimed to explore understandings of consumer participation from a manager's perspective. Semistructured interviews were conducted with seven participants in this qualitative, interpretive study. The thematic analysis revealed the complexities around defining consumer participation and demonstrated the difficulties and possible reasons as to why there is no real clarity between managers, service providers, and consumers as to what consumer participation should look like. Power and change were the primary themes. Power and the overwhelming consensus that the medical model and those working within it hold the most power was strongly represented in this study. Legislation and workplace settings were seen as considerable factors adding to the disempowerment of consumers within an already disempowering mental health system. Change was the other main theme that emerged, with culture and attitudes of the old 'institutionalized' thinking that still pervades some pockets of mental health services being seen as the major barriers to change. The role of the consumer consultant was a prominent subtheme, with their role in training and the education of workers seen as an essential and positive way to progress consumer participation. These findings demonstrate that managers consider there to be hope for consumers, brought about by collective action and lobbying, and through consumer participation in less-restrictive parts of the service (community settings).     

User involvement in mental health care: the role of nurses. A literature review

This literature review was carried out to examine the effects of user involvement in shared decision-making processes and the methods/tools available to psychiatric nurses to measure and encourage user involvement. A systematic literature review was then used in this study. Many studies indicate that an increased involvement of service users leads to better care, better treatment compliance, improved health outcomes and higher levels of patient satisfaction. The tools and methods described are designed to measure the ability to participate, the process of implementation and the evaluation of healthcare services. An adequate instrument to measure user involvement will be necessary to underpin the positive effects. Although care providers have a statutory duty to help shape user involvement, and the tools required are available, care providers are still insufficiently inclined to take up this duty.     

Trauma-informed care in acute mental health units through the lifeworld of mental health nurses: A phenomenological study

Trauma-informed care has gained increasing popularity in mental health services over the past two decades. Mental health nurses remain one of the largest occupations employed in acute mental health settings and arguably have a critical role in supporting trauma-informed care in this environment. Despite this, there remains a limited understanding on how trauma-informed care is applied to the context of mental health nursing in the hospital environment. The aim of this study was to explore what it means for mental health nurses to provide trauma-informed care in the acute mental health setting. The study design was qualitative, using van Manen's (Researching lived experience: human science for an action sensitive pedagogy. State University of New York Press, 1990) approach to hermeneutic phenomenological inquiry. A total of 29 mental health nurses participated in this study. There were three overarching themes that emerged; these entail: embodied trauma-informed milieu, trauma-informed relationality and temporal dimensions of trauma-informed mental health nursing. The study found that for mental health nurses, there are elements of trauma-informed care that extend far beyond the routine application of the principles to nursing practice. For mental health nurses working in the acute setting, trauma-informed care may offer a restorative function in practice back to the core tenants of therapeutic interpersonal dynamics it was once based upon.     

Risky business: Lived experience mental health practice,nurses as potential allies

Mental health policy includes a clear expectation that consumers will participate in all aspects of the design and delivery of mental health services. This edict has led to employment roles for people with lived experience of significant mental health challenges and service use. Despite the proliferation of these roles, research into factors impacting their success or otherwise is limited. This paper presents findings from a grounded theory study investigating the experiences of Lived Experience Practitioners in the context of their employment. In‐depth interviews were conducted with 13 Lived Experience Practitioners. Risk was identified as a core category, and included sub‐categories: vulnerability, ‘out and proud’, fear to disclose, and self‐care. Essentially participants described the unique vulnerabilities of their mental health challenges being known, and while there were many positives about disclosing there was also apprehension about personal information being so publically known. Self‐care techniques were important mediators against these identified risks. The success of lived experience roles requires support and nurses can play an important role, given the size of the nursing workforce in mental health, the close relationships nurses enjoy with consumers and the contribution they have made to the development of lived experience roles within academia.     

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.     

Service user involvement in care planning: the mental health nurse's perspective

A dissonance between espoused values of consumerism within mental health care and the 'reality' of clinical practice has been firmly established in the literature, not least in terms of service user involvement in care planning. In order to begin to minimize such dissonance, it is vital that mental health nurse perceptions of service user involvement in the core activity of care planning are better understood. The main findings of this qualitative study, which uses semistructured interviews, suggest that mental health nurses value the concept of user involvement but consider it to be problematic in certain circumstances. The study reveals that nurses hold similar views about the 'meaning' of patient involvement in care planning but limited resources, individual patients characteristics and limitations in nursing care are the main inhibiting factors. Factors perceived as promoting and increasing user involvement included: provision of accurate information, 'user-friendly' documentation, mechanisms for gaining service user feedback, and high staff morale.     

The experience and views of mental health nurses regarding nursing care delivery in an integrated, inpatient setting

Positive and effective consumer outcomes hinge on having in place optimal models of nursing care delivery. The aim of this study was to ascertain the experience and views of mental health nurses, working in hospitals in an area mental health service, regarding nursing care delivery in those settings. Surveys (n = 250) were sent to all mental health nurses working in inpatient settings and 118 (47%) were returned. Results showed that the quality of nursing care achieved high ratings (by 87%), and that two-thirds of respondents were proud to be a mental health nurse and would choose to be a mental health nurse again. Similarly, the majority (71%) would recommend mental health nursing to others. Concern was, however, expressed about the continuity and consistency of nursing work and information technology resources. Nurses with community experiences rated the importance of the following items, or their confidence, higher than those without previous community placements: the importance of interdisciplinary teamwork; the importance of participating in case review; the importance of collaborating with community staff; confidence in performing mental state examinations; and confidence in collaborating with community staff, suggesting that this placement had positive effects on acute care nursing.     

Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards

Quality nursing plays a central role in the delivery of contemporary health and social care, with a positive correlation being demonstrated between patient satisfaction and the quality of nursing care received. One way to ensure such quality is to develop metrics that measure the effectiveness of various aspects of care across a variety of settings. Effective mental health nursing is predicated on understanding the lived experiences of service users in order to provide sensitively‐attuned nursing care. To achieve this, mental health nurses need to establish the all‐important therapeutic relationship, showing compassion and creating a dialogue whereby service users feel comfortable to share their experiences that help contextualize their distress. Indeed, service users value positive attitudes, being listened to, and being able to trust those who provide care, while mental health nurses value their ability to relate through talking, listening, and expressing empathy. However, the literature suggests that within mental health practice, a disproportionate amount of time is taken up by other activities, with little time being spent listening and talking to service users. The present study discusses the evidence relating to the therapeutic relationship in acute mental health wards and explores why, after five decades, it is not recognized as a fundamental metric of mental health nursing.     

A role for mental health nursing in the physical health care of consumers with severe mental illness

There is extensive international evidence that people with severe mental illness have a lower standard of physical health than the general population. This leads to higher morbidity and mortality rates. Many of the causes for this poor physical health are modifiable. Yet the physical needs of this consumer group are neglected by healthcare systems in Australia, and elsewhere. While medical specialists are clearly integral to remedying this, nurses are well placed to play a key role in focused prevention and early intervention in the physical well-being of consumers with mental health problems. This paper outlines the specifics on how mental health nurses can be sensitized, prepared and empowered to help turn this serious health issue around. In particular, mental health nurses could be trained in and then utilize a new physical health check and response system in the UK (called the Health Improvement Profile) if adapted for use within Australia. This profile will be briefly introduced, and then its value to improving health care discussed.     

Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: Associations and impact on aggressive behaviour

Aim and objectives

To examine associations between risk of aggression and nursing interventions designed to prevent aggression.

Background

There is scarce empirical research exploring the nature and effectiveness of interventions designed to prevent inpatient aggression. Some strategies may be effective when patients are escalating, whereas others may be effective when aggression is imminent. Research examining level of risk for aggression and selection and effectiveness of interventions and impact on aggression is necessary.

Design

Archival case file.

Methods

Data from clinical files of 30 male and 30 female patients across three forensic acute units for the first 60 days of hospitalisation were collected. Risk for imminent aggression as measured by the Dynamic Appraisal of Situational Aggression, documented nursing interventions following each assessment, and acts of aggression within the 24‐hours following assessment were collected. Generalised estimating equations were used to investigate whether intervention strategies were associated with reduction in aggression.

Results

When a Dynamic Appraisal of Situational Aggression assessment was completed, nurses intervened more frequently compared to days when no Dynamic Appraisal of Situational Aggression assessment was completed. Higher Dynamic Appraisal of Situational Aggression assessments were associated with a greater number of interventions. The percentage of interventions selected for males differed from females; males received more pro re nata medication and observation, and females received more limit setting, one‐to‐one nursing and reassurance. Pro re nata medication was the most commonly documented intervention (35.9%) in this study. Pro re nata medication, limit setting and reassurance were associated with an increased likelihood of aggression in some risk bands.

Conclusions

Structured risk assessment prompts intervention, and higher risk ratings result in more interventions. Patient gender influences the type of interventions. Some interventions are associated with increased aggression, although this depends upon gender and risk level.

Relevance to clinical practice

When structured risk assessments are used, there is greater likelihood of intervention. Intervention should occur early using least restrictive interventions.