Crisis resolution and home treatment in the UK: A survey of model fidelity using a novel review methodology

Crisis resolution teams (CRTs) provide treatment at home to people experiencing mental health crises, as an alternative to hospital admission. Previous UK research, based on self‐report surveys, suggests that a loosely specified model has resulted in wide variations in CRTs’ service delivery, organization and outcomes. A fidelity scale (developed through evidence review and stakeholder consensus) provided a means of objectively measuring adherence to a model of good practice for CRTs, via one‐day fidelity reviews of UK crisis teams. Reviews included interviews with service users, carers, staff and managers, and examination of data, policies, protocols and anonymized case notes. Of the 75 teams reviewed, 49 (65%) were assessed as being moderate fidelity and the rest as low fidelity, with no team achieving high fidelity. The median score was 122 (range: 73–151; inter‐quartile range: 111–132). Teams achieved higher scores on items about structure and organization, for example ease of referral, medication and safety systems, but scored poorly on items about the content of care and interventions. Despite a national mandate to implement the CRT model, there are wide variations in implementation in the UK and no teams in our sample achieved overall high fidelity. This suggests that a mandatory national policy is not in itself sufficient to achieve good quality implementation of a service model. The CRT Fidelity Scale provides a feasible and acceptable means to objectively assess model fidelity in CRTs. There is a need for development and testing of interventions to enhance model fidelity and facilitate improvements to these services.     

Unveiling new dimensions: a hermeneutic exploration of perinatal mood disorder and infant feeding

In this hermeneutic study, six women from the local Perinatal Mental Health Program were interviewed about their experiences with infant feeding. None of the women in the study were breastfeeding their infants. The research question centered on their experience of formula feeding with a view to gaining better insight about the issues that women face when feeding practices do not conform to best-practice (i.e., breastfeeding) promotional standards. We also considered the needs of nurses working in the mental health setting, who may face conflicting recommendations concerning the treatment of a mental health crisis in the presence of current infant feeding best-practice guidelines. Our findings support concerns that current guidelines overlook the special needs of women who live with perinatal mood disorder. We speculate that breastfeeding challenges may present a risk for postpartum depression in women who are biologically vulnerable. The need for ongoing assessment for emerging depression among women who are experiencing breastfeeding challenges is identified. The importance of deepened understanding among mental health nurses is highlighted.     

Assessing the knowledge of perinatal mental illness among student midwives

The experience of perinatal mental illness (mental illness occurring around the time of pregnancy) currently affect 1 in 10 women and can have adverse effects on the mother and her child (Massie and Szajnberg, 2002; O'Connor et al., 2002). The care and effective management of women experiencing perinatal mental illness is therefore an important issue for health care staff, managers, psychiatrists, commissioners and campaigners. Midwives play a significant part in caring for women throughout their pregnancies, during labour and up to the first month after birth. Midwives are in a unique position to assess a woman's well-being and to offer appropriate support. However, previous research has revealed that midwives often have poor understanding and knowledge of perinatal mental health issues and require improved training (Ross-Davie et al, 2006; McCann and Clark, 2010).This research project aims to systematically assess student midwives awareness of perinatal mental illness. The findings of this study will inform curriculum development for graduate and post-graduate midwifery students therefore improving the care and support women with mental illness receive from antenatal services. The findings from this study will also be used for the formation of an educational web-based programme for student and qualified midwives.     

Implementing a Safety Bundle to Improve Screening and Care for Perinatal Mood and Anxiety Disorders

ObjectiveTo improve screening and care of individuals with perinatal mood and anxiety disorders (PMAD) through the implementation of a perinatal mental health safety bundle.DesignRapid-cycle quality improvement model using four plan–do–study–act cycles over the course of 90 days. Individuals between 28 and 32 weeks gestation and at their 6-week postpartum follow-up visit were screened and offered stage-based care for PMAD.Setting/Local ProblemAt baseline, only 15% of clients of a suburban, private-practice women’s health clinic were receiving PMAD screening with a validated tool, and the site lacked standardized PMAD care practices among health care providers.ParticipantsHealth care providers (n = 2), staff (n = 4), and eligible patients (n = 78) at a private-practice women’s health clinic.Intervention/MeasurementsA screening, brief intervention, referral, and treatment/follow-up (SBIRT) model was used to screen eligible patients, provide treatment options, and appropriately refer for follow-up to mental health services. Team engagement occurred via weekly meetings. Measurements included pre–post maternal and team engagement survey results, biweekly chart review, and run chart analysis.ResultsEffective PMAD screening and right care were achieved for 85% of eligible individuals; this included receiving screening, referral to treatment, a scheduled mental health appointment, and clinic follow-up to ensure mental health care uptake.ConclusionUse of the SBIRT model to implement a safety bundle may contribute to improved mental health outcomes for individuals receiving perinatal care in a private-practice outpatient health care setting. Education and engagement among clinicians, staff, and patients are key to successful implementation of a safety bundle.     

Needs and risks of patients in a state‐wide inpatient forensic mental health population

Routine needs assessments have become mandated requirements for public mental health services. However, the appropriateness of these generic health needs assessments to specialist populations remains questionable. This study sought to assess individual needs assessed using a widely used clinician rated assessment (Health of the Nation Outcome Scales‐Secure; HoNOS‐Secure), a subjective needs assessment that considers both staff and patient perspectives (Camberwell Assessment of Need‐Forensic version; CANFOR), and a measure of risk for general criminal recidivism (Level of Service Inventory: Screening Version; LSI:SV) in a secure forensic mental health service. Results revealed significant positive correlations between staff ratings on HoNOS‐Secure, CANFOR total needs, and CANFOR met needs scores, but no significant association between CANFOR ratings or HoNOS‐Secure ratings and LSI:SV scores. Although patients and staff reported the same number of needs overall according to CANFOR (7.2 vs. 7.5, P > 0.05), patients reported that more of these needs were unmet (3.1 vs. 2.3, P < 0.05). Differences between staff and patient ratings of need suggest that needs assessments should include patient perspectives to facilitate more collaborative and comprehensive care planning. Divergent perspectives between patients and staff may impair patient engagement in treatment and therefore negatively impact on outcome. Service planning issues and opportunities for future research are discussed.     

The practicability and relevance of developing a yoga intervention for mental health consumers: A qualitative study

The aim of the study was to understand the perspectives of mental health consumers, staff, and yoga teachers on the characteristics of a yoga‐based intervention to be developed for consumers with a long‐term mental health condition, in addition to anxiety and/or depression. Two focus groups were held with mental health consumers (n = 8), two focus groups with mental health staff (n = 13) from a metropolitan community mental health setting, and five one‐on‐one interviews with yoga teachers. Participants were asked about the feasibility and appropriateness of a range of yoga practice features to be tested as a newly developed yoga‐based intervention. Thematic analysis was used to identify themes. Findings included the following consumer themes: Mental health understanding and experience of teachers and participants is important, Creating a safe space and Yoga practice elements. Staff themes included Mental health understanding and experience of teachers is important, Environmental design, and Yoga practice elements. Yoga teacher themes included Environmental design and Yoga practice elements. Mental health understanding and experience of the yoga teacher, and trauma‐informed care were consistently emphasized by consumers and staff. Teachers focused less on specific mental health considerations, which may be reflective of a broader knowledge gap. Recommendations regarding yoga practice elements, including pre‐information, regular and consistent practice, modifications, breathwork, mindfulness and guided practice, and environmental design features, were consistent with current trauma‐informed yoga research. Findings will be used to guide the development of a yoga‐based intervention for consumers with a long‐term mental health condition, in addition to anxiety and/or depression.     

Providing physical health care for people accessing mental health services: Clinicians’ perceptions of their role

The prevalence of health risk behaviours and associated poor physical health is high in people with severe mental illness. Mental health service guidelines and policies stipulate that mental health services should address physical health of people who access services. This study reports results from a large, interdisciplinary, cross‐sectional study exploring mental health clinicians’ (n = 385) views of role legitimacy in physical health service provision. All disciplines reported that mental health clinicians have a role to play in addressing the physical health of consumers. Among mental health clinicians, psychiatrists and mental health nurses received higher endorsement than allied health clinicians in relation to the provision of physical health care, with primary care providers including general practitioners also ranking highly. As community mental health services routinely appoint allied health staff to case management roles, a challenge for services and a challenge for clinicians are to ensure that physical health and the effects of medication are monitored appropriately and systematically. Online and telephone support services received relatively lower endorsement. As the availability of nonface to face services increases, there is a need to explore their utility in this population and where appropriate promote their uptake.     

Police and mental health clinician partnership in response to mental health crisis: A qualitative study

Police officers as first responders to acute mental health crisis in the community, commonly transport people in mental health crisis to a hospital emergency department. However, emergency departments are not the optimal environments to provide assessment and care to those experiencing mental health crises. In 2012, the Northern Police and Clinician Emergency Response (NPACER) team combining police and mental health clinicians was created to reduce behavioural escalation and provide better outcomes for people with mental health needs through diversion to appropriate mental health and community services. The aim of this study was to describe the perceptions of major stakeholders on the ability of the team to reduce behavioural escalation and improve the service utilization of people in mental health crisis. Responses of a purposive sample of 17 people (carer or consumer advisors, mental health or emergency department staff, and police or ambulance officers) who had knowledge of, or had interfaced with, the NPACER were thematically analyzed after one‐to‐one semistructured interviews. Themes emerged about the challenge created by a stand‐alone police response, with the collaborative strengths of the NPACER (communication, information sharing, and knowledge/skill development) seen as the solution. Themes on improvements in service utilization were revealed at the point of community contact, in police stations, transition through the emergency department, and admission to acute inpatient units. The NPACER enabled emergency department diversion, direct access to inpatient mental health services, reduced police officer ‘down‐time’, improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition.     

Needs of individuals recovering from a first episode of mental illness: A scoping review

Central to the role of mental health clinicians is the assessment of needs. A number of assessment tools have been used to evaluate the needs of individuals diagnosed with a mental illness. These tools have largely been developed for people with a severe and persistent mental illness and may not be suitable for individuals who are recovering from a first episode of mental illness. The aims of this review were therefore to identify the needs experienced by individuals recovering from a first episode of mental illness; determine what tools have been used to evaluate these needs; and explore whether existing tools adequately reflect the needs described in the literature. Twenty‐one articles were included, comprising articles which identified needs (n = 10), needs assessment tools (n = 1), or articles which identified both needs and a needs assessment tool (n = 10). Results indicate that individuals who have been admitted to a specialized mental health unit and are recovering from a first episode of mental illness may experience an extensive range of needs, spanning emotional, psychological, social, informational, functional, practical, and relationship needs. Four established needs assessment tools were found to have been used to evaluate these needs; however, these do not appear to represent all needs discovered in this review, were mostly developed for populations with a long‐term mental illness, and may not be suitable for assessing the needs of individuals recovering from a first episode of mental illness following a presentation to a specialized mental health unit.     

‘Anyone can have a mental illness’: A qualitative inquiry of pre‐registration nursing students’ experiences of traditional mental health clinical placements

Nurses play a crucial role in mental healthcare provision. Like many countries, Australian nursing students are educated in comprehensive pre‐registration programmes which include mental health clinical placements. Placements play a vital role in students’ education, providing the opportunity to engage with consumers and develop mental health nursing knowledge and skills. There is limited knowledge of student perspectives on traditional placements in contemporary recovery‐oriented mental health services. This interpretive qualitative inquiry aimed to explore nursing students’ experience of traditional mental health clinical placement and how it influenced their practice and their understandings of recovery from mental illness. Data were collected from focus groups with n = 31 nursing students in a large metropolitan public mental health service. Thematic analysis resulted in three themes of experience: humanizing people with mental illness; learning about recovery; and shifting perspectives on mental health nursing. Through a positive placement experience where they felt supported and included by staff, students came to see consumers as people rather than diagnoses, developed greater understanding of mental health nursing work and were more likely to consider mental health nursing as a career choice. Peer‐support workers were an important influence on students’ understandings of recovery and have a key role to play in educating students on placement. Students need to be prepared and supported by university and clinical staff to deal with vicarious trauma that may occur on placement. Mental health placements play a crucial role in attracting students into the field, and it is imperative they remain part of comprehensive pre‐registration education.     

Lived experience of involuntary transport under mental health legislation

Police have historically been responsible for transporting people during a mental health crisis in Australia. A major change to the New South Wales (NSW) Mental Health Act (MHA) in 2007 expanded the range of coercive transportation agencies to include NSW Ambulance (paramedics) and NSW Health (mental health nurses). Anecdotal reports, however, describe a lack of clarity around how these changes should be implemented in practice. This research aims to explore this lack of clarity through qualitative analysis of interviews with people with the lived experience of involuntary transport under the MHA. Sixteen interviews were conducted; most (n = 14) interviews in northern NSW regions: six with people who had been transported (consumers), four with carers, and six with service providers (two police, one paramedic, and three mental health nurses). For consumers and carers, the police response was often perceived as too intense, particularly if the person was not violent. Carers were often conflicted by having to call for emergency intervention. Service providers were frustrated by a lack of a coordinated interagency response, resourcing issues, delays at emergency departments, and lack of adequate training. A central theme across all groups was the importance of communication styles. As one participant (consumer) said: ‘Everybody needs a lesson in kindness’. All groups agreed that high‐risk situations necessitate police involvement. However, invocation of the MHA during a high‐risk situation is fraught with stress and difficulties, leaving little room for empathetic communications. Effective and diverse, evidence‐based, early intervention strategies – both consensual and non‐consensual – are necessary to reduce the requirement for police involvement in mental health transports.     

Practitioners’ application of Let’s Talk about Children intervention in adult mental health services

Family‐focused interventions can improve outcomes for families where a parent has a mental illness. One such intervention, Let’s Talk about Children (Let’s Talk), is a series of parent–practitioner conversations in adult mental health with demonstrated improved outcomes for child, parent, and family well‐being. This study used a questionnaire to understand the application of Let’s Talk by n = 73 trained practitioners from eight adult mental health services who were previously involved in a randomized controlled study in Victoria, Australia. Data were analysed to establish the application of Let’s Talk, and statistical analyses were undertaken to identify what influenced practitioners’ delivery of Let’s Talk. The study details how practitioners used Let’s Talk and indicates that most used it as designed, with the majority offering it to parents and approximately 40% delivering it. The findings indicate there is a decline over time in both the number of practitioners using Let’s Talk and the number of deliveries over time. Practitioners’ use of Let’s Talk was influenced by their gender, profession, access to support, time since training, and caseload. The article discusses the implications of these results for sustaining Let’s Talk in adult mental health services. While this study gives a baseline of practitioners’ application of Let’s Talk, further exploration of the experience of practitioners and parents as well as other system factors will be helpful to understand barriers and enablers to continued practice.     

Effectiveness of home visits by mental health nurses for Japanese women with post‐partum depression

Post‐partum depression affects 10–13% of Japanese women, but many do not receive appropriate treatment or support. This intervention study evaluated the effectiveness of home visits by mental health nurses for Japanese women with post‐partum depression. Eighteen post‐partum women met the inclusion criteria and were randomly allocated into the intervention (n = 9) or control (n = 9) group at 1–2 months after giving birth. The intervention group received four weekly home visits by a mental health nurse. Control group participants received usual care. Two women in the intervention group did not complete the study. Depressive symptoms and quality of life were measured at 1 and 6 weeks' postintervention. In addition, participants completed an open‐ended questionnaire on satisfaction and meaning derived from the home visits. Women in the intervention group had significant amelioration of depressive symptoms over time and reported positive benefits from the home visits, but there were no statistically significant differences between groups. Significant differences (P < 0.05) were observed at times 2 and 3 between groups in terms of increased median scores of physical, environmental, and global subscales, and the total average score of the World Health Organization/quality of life assessment instrument. On the psychological subscale, significant differences (P = 0.042) were observed between groups at time 2. The qualitative analysis of comments about home visitation revealed four categories related to ‘setting their mind at ease’, ‘clarifying thoughts’, ‘improving coping abilities’, and ‘removing feelings of withdrawal from others’. These results suggest that home visits by mental health nurses can contribute to positive mental health and social changes for women with post‐partum depression. A larger trial is warranted to test this approach to care.     

Improving the physical health of people with severe mental illness in a low secure forensic unit: An uncontrolled evaluation study of staff training and physical health care plans

The life expectancy of people with severe mental illnesses is substantially reduced, and monitoring and screening for physical health problems is a key part of addressing this health inequality. Inpatient admission presents a window of opportunity for this health‐care activity. The present study was conducted in a forensic mental health unit in England. A personal physical health plan incorporating clearly‐presented and easily‐understood values and targets for health status in different domains was developed. Alongside this, a brief physical education session was delivered to health‐care staff (n = 63). Printed learning materials and pedometers and paper tape measures were also provided. The impact was evaluated by a single‐group pretest post‐test design; follow‐up measures were 4 months’ post‐intervention. The feasibility and acceptability of personal health plans and associated resources were examined by free‐text questionnaire responses. Fifty‐seven staff provided measures of attitudes and knowledge before training and implementation of the physical health plans. Matched‐pairs analysis indicated a modest but statistically‐significant improvement in staff knowledge scores and attitudes to involvement in physical health care. Qualitative feedback indicated limited uptake of the care plans and perceived need for additional support for better adoption of this initiative. Inpatient admission is a key setting for assessing physical health and promoting improved management of health problems. Staff training and purpose‐designed personalized care plans hold potential to improve practice and outcomes in this area, but further support for such innovations appears necessary for their uptake in inpatient mental health settings.     

What is needed for Trauma Informed Mental Health Services in Australia? Perspectives of clinicians and managers

Trauma Informed Care is an approach to the delivery of mental health care that requires sensitivity to the prevalence and effects of trauma in the lives of people accessing services. While TIC is increasingly emphasized in mental health policy and frameworks in Australia, people working in mental health settings have reportedly struggled to translate the values and principles into their everyday practice. This qualitative study used an experience‐based co‐design methodology to explore the potential for implementation of Trauma Informed Care into mental health services in Australia. The experiences of consumers, carers, clinicians, and managers were gathered. This paper presents the perspectives of clinicians (n = 64) and senior managers (n = 9) from across three Local Health Districts in New South Wales in Australia. All data were analysed thematically to address the research question: What is needed for Trauma Informed Mental Health Services in Australia? To be trauma‐informed, managers required: leadership at all levels, access to resource, relevant and accessible training, support for staff, resolution of wider systems issues, and clarification of the concept and actions of TIC. Clinicians identified that to be trauma‐informed they required services to: be aware of staff well‐being, support different ways of working, address workplace cultures and provide increased resources. The findings have implications for any service, team or individual seeking to implement TIC within mental health settings.     

The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff

Inpatient aggression on mental health wards is common and staff–patient interactions are frequently reported antecedents to aggression. However, relatively little is known about the precise relationship between aggression and these interactions, or their relationships with aggression and staff containment responses such as restraint and seclusion. This study aimed to determine the roles of anger and interpersonal style among mental health nurses and between nurses and patients in the occurrence of aggression and its containment. A correlational, pseudoprospective study design was employed. n = 85 inpatients and n = 65 nurses were recruited from adult, low‐ and medium‐secure wards of a secure forensic mental health service. Participants completed validated self‐report anger and transactional interpersonal style measures. Inpatient aggression and containment incident data for a 3‐month follow‐up period were extracted from clinical records. Dyadic nurse–patient relationships were anticomplementary. Patients' self‐reported anger and staff‐rated hostile interpersonal style were significantly positively correlated; staff self‐reported anger and patient‐rated dominant interpersonal style were also positively correlated. Patient anger predicted aggression and their interpersonal style predicted being subject to containment in the form of restraint and seclusion. There were no statistically significant differences identified on measures between staff who were and were not involved in containment. More targeted intervention for patients' anger may have a positive impact on interpersonal style and lead to the reduction of incidents. Staff education and skills training programmes should emphasize the importance of interpersonal styles which could help to promote and enhance positive interactions.     

Does clinical placement in a community alcohol and other drugs rehabilitation centre influence students’ career intention?

Due to an ageing workforce, there is a growing need for greater numbers of nurses to work in areas, such as mental health and alcohol and other drugs (AOD) rehabilitation. These practitioners need to approach their work as ‘recovery‐oriented practitioners’. Positive experiences and preceptorship during clinical placement in AOD rehabilitation settings might influence students’ later career choices and address some of the workforce shortage issues. The aim of the present concurrent, mixed‐methods study was to explore students’ perceptions of their clinical placement experience in a community‐based AOD rehabilitation setting, and to examine attitude, career intention, and satisfaction with the placement. Fifty‐eight students completed pre–post‐test surveys, with closed and open‐ended questions, which included standardized measures. A small sample of survey respondents also agreed to participate in a semistructured interview. The quantitative results revealed two predictors for higher intention to pursue a career in AOD: (i) a high satisfaction with their clinical placement (β = 0.29, P = 0.008); and (ii) a high baseline attitude to recovery‐oriented practice (β = 0.28, P = 0.013). The qualitative findings identified five factors influencing placement experience: (i) educational factors; (ii) students’ background factors; (iii) placement factors; (iv) client factors; and (v) staff factors. A model that synthesizes the quantitative and qualitative findings was also developed. In conclusion, clinical placement in a community‐based AOD rehabilitation centre improved students’ intention to work in that setting.     

Predictors for clinical deterioration of mental state in patients assessed by telephone‐based mental health triage

Patient safety research focussing on recognizing and responding to clinical deterioration is gaining momentum in generalist health, but has received little attention in mental health settings. The focus on early identification and prompt intervention for clinical deterioration enshrined in patient safety research is equally relevant to mental health, especially in triage and crisis care contexts, yet the knowledge gap in this area is substantial. The present study was a controlled cohort study (n = 817) that aimed to identify patient and service characteristics associated with clinical deterioration of mental state indicated by unplanned admission to an inpatient psychiatric unit following assessment by telephone‐based mental health triage. The main objective of the research was to produce knowledge to improve understandings of mental deterioration that can be used to inform early detection, intervention, and prevention strategies at the point of triage. The results of the study found that the clinical profile of admitted patients was one of complexity and severity. Admitted patients were more likely to have had complex psychiatric histories with multiple psychiatric admissions, severe psychotic symptoms, a history of treatment non‐adherence, and poorer social functioning than non‐admitted patients.