Inpatient staff perceptions in providing care to individuals with co-occurring mental health problems and illicit substance use

ACCESSIBLE SUMMARY: This paper reports on a piece of research which is summarized below. ? This research explored how mental health inpatient staff, (including nurses, doctors and other professional disciplines) experience caring for patients who both have mental health problems and who use illicit drugs. (Illicit drugs are illegal drugs which incur a criminal prosecution for possession and/or use). The results of the study were gathered from questionnaires and interviews which asked staff about their viewpoints and experiences. ? The questionnaire results included a section which measured staff attitude towards patients who use illicit drugs and who have mental health problems. Staff who had received training in how to work with people with these problems were found to have a less negative attitude towards these patients. The length of time staff members had worked in their posts or had worked in a particular setting did not have any effect on their attitude. For example, their attitude was not more or less negative towards patients with these problems. ? Ten members of staff were interviewed to find out more in-depth information about their viewpoints and experiences. Overall, these staff members reported a lack of training, difficulty in accessing support and problematic issues within the teams they worked. ? This paper highlights the importance of training to support staff in working with mental health patients who use illicit drugs; and how this affects staff attitude positively towards patients with these problems. ABSTRACT: The extent of illicit substance use within inpatient mental health settings is becoming a major cause of concern. This poses growing challenges not only for the management of inpatient units, but also for providing continuity of care. Service users with co-occurring substance use are more likely to disengage from services. The process of engagement can be hindered by negative attitudes of staff. This study aimed to identify and explore multidisciplinary staff attitudes and experiences in caring for inpatients with co-occurring ill-mental health problems and illicit substance use. A questionnaire incorporating the Drug and Drugs Problems Perceptions Questionnaire (DDPPQ) was used with a non-probability sample of 84 multidisciplinary staff working on nine mental health units. Semi-structured interviews were then carried out with 10 members of staff. Overall, respondents reported: lack of training; difficulty in accessing support structures; and problematic issues with multidisciplinary decision making and processes. The DDPPQ results showed that staff who had received training held less negative attitudes towards illicit substance users regardless of their length of clinical work experience or type of work setting. Recommendations are made about the importance of training and staff support for the development of less negative attitudes towards this client group.     

Learning from incidents of violence in health care. An investigation of 'case reports' as a basis for staff development and organisational change.

How can health care staff be helped by learning about aggression and violence in health care settings. This is a report of how 'Case Reports' were used as a basis for staff development through educational intervention and organisational change. The project was carried out in two stages. Firstly, 'Case Reports' were collected to document and illuminate the experiences of health care staff, and these reports were used as a basis for teaching and learning. Secondly, opportunities were provided for health care staff to review existing policies and guidelines relevant to aggression and violence in health care settings. The views of 253 health care staff from five Health Authorities were explored. Health care staff reported 1) experiencing verbal abuse, hostility, actual contact violence, fears and anxieties during work; 2) that although they were exposed to aggression and/or actual contact violence, training was sparse or non-existent; 3) that policies and guidelines where they existed were out of data and were not relevant to the variety of health care settings in which they worked; and 4) that their skills in this area could be improved through training, with particular attention to listening skills, facilitation skills; verbal and non-verbal communication and assertion skills.     

The Correctional Officer’s Role in Mental Health Treatment of Youthful Offenders

This paper explores issues specific to the provision of effective mental health treatment for juvenile offenders within juvenile justice departments. A multifaceted treatment approach in this setting should include security officers as well as the customary mental health and medical professionals. Confidentiality issues direct correctional policies that require medical, mental health, and security records to remain separate. Such limitations in the exchange of information reduce the likelihood that correctional officers would be considered as part of the treatment team. With the high inmate to professional staff ratio and the growing attention to outcomes, (his approach needs to be considered.     

The correctional Officer's role in Mental Health treatment of youthful offenders

This paper explores issues specific to the provision of effective mental health treatment for juvenile offenders within juvenile justice departments. A multifaceted treatment approach in this setting should include security officers as well as the customary mental health and medical professionals. Confidentiality issues direct correctional policies that require medical, mental health and security records to remain separate. Such limitations in the exchange of information reduce the likelihood that correctional officers would be considered as part of the treatment team. With high inmate to professional staff ratio and the growing attention to outcomes, this approach needs to be considered.     

Clinical Placements in Mental Health: A Literature Review

Gaining experience in clinical mental health settings is central to the education of health practitioners. To facilitate the ongoing development of knowledge and practice in this area, we performed a review of the literature on clinical placements in mental health settings. Searches in Academic Search Complete, CINAHL, Medline and PsycINFO databases returned 244 records, of which 36 met the selection criteria for this review. Five additional papers were obtained through scanning the reference lists of those papers included from the initial search. The evidence suggests that clinical placements may have multiple benefits (e.g. improving students’ skills, knowledge, attitudes towards people with mental health issues and confidence, as well as reducing their fears and anxieties about working in mental health). The location and structure of placements may affect outcomes, with mental health placements in non-mental health settings appearing to have minimal impact on key outcomes. The availability of clinical placements in mental health settings varies considerably among education providers, with some students completing their training without undertaking such structured clinical experiences. Students have generally reported that their placements in mental health settings have been positive and valuable experiences, but have raised concerns about the amount of support they received from education providers and healthcare staff. Several strategies have been shown to enhance clinical placement experiences (e.g. providing students with adequate preparation in the classroom, implementing learning contracts and providing clinical supervision). Educators and healthcare staff need to work together for the betterment of student learning and the healthcare professions.     

Patterns of use, attitudes and expectations of mental health staff regarding computers

There is limited information on the views of mental health staff about computers. The present study aimed to ascertain the patterns of use, attitudes and expectations of staff from a comprehensive mental health service regarding computers before and after the purchase of new equipment and training. A questionnaire was sent to staff of the Central Sydney Mental Health Services working in sites targeted for new computer equipment and training. Most respondents, especially those with computer experience or who had worked in mental health for less than 5 years, viewed computers favourably. At the same time, half the respondents did not feel they had sufficient access to a computer at work and the vast majority had not received training as intended. Commitments to provide computer equipment and training must be followed through, otherwise staff may feel disenchanted and computers may be regarded less favourably. A measure of the positive views about computer use ('positivity index') developed during the course of the current study may have wider applicability.     

Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings

Many countries now have national mental health policies and guidelines to decrease or eliminate the use of seclusion and restraint yet the use of Pro Re Nata (PRN) medications has received less practice evaluation. This research aimed to identify mental health nurses' attitudes towards the use of PRN medications with mental health consumers. Participants were working in forensic mental health and non‐forensic acute mental health settings. The “Attitudes towards PRN medication use survey” was used and data were collected online. Data were analysed using the Statistical Package Social Sciences, Version 22.0. Practice differences between forensic and other acute mental health settings were identified related to the use of PRN medications to manage symptoms from nicotine, alcohol and other drug withdrawal. Differences related to the useage of comfort rooms and conducting comprehensive assessments of consumers' psychiatric symptoms were also detected. Qualitative findings highlighted the need for increased accountability for the prescribing and administration of PRN medications along with more nursing education/training to use alternative first line interventions. Nurses administering PRN medications should be vigilant regarding the indications for this practice to ensure they are facilitating the consumer's recovery by reducing the use of all forms of potentially restrictive practices in the hospital setting. The reasons for using PRN medications and PRN administration rates must be continually monitored to avoid practices such as high dose antipsychotics use and antipsychotic polypharmacy to ensure the efficacy of the consumers' management plans on their health care outcomes.     

Patients’ Perceptions of What Makes a Good Doctor and Nurse in an Israeli Mental Health Hospital

The aim of this study was to identify inpatients’ expectations of their doctors and nurses in a mental health hospital setting. Individual interviews were conducted with 72 inpatients of a large mental health hospital in northern Israel. Our study produced three major results. First, most patients, whatever their emotional status, share similar expectations of staff, of which the most conspicuous is that they be respected as whole persons and that staff not treat them merely as cases of illness. Second, they expect to be involved in making decisions about their treatment, including being informed of reports and records referring to them. Third, patients expect all hospital staff, particularly nurses, to provide them with emotional support. The findings of this study can be used to facilitate improved care of mental health inpatients by both doctors and nurses. Structured and methodical examinations of inpatients’ expectations at the time they are hospitalized can help adjust not only the professional aspect of health care but also the therapeutic communication approach to patients’ individual needs.     

The primary and secondary care interface: the educational needs of nursing staff for the provision of seamless care

AIM: To identify nurses' perceived deficits in the knowledge and skills required to provide effective seamless care, so that appropriate training could be provided. BACKGROUND: A clear understanding of nursing staff roles, skills and resources is paramount to work at the primary/secondary care interface. Nursing staff require an educational model that will provide a clear understanding of how their roles coalesce with other healthcare professionals. There is little evidence that examines the educational needs of nurses related to changing care boundaries. DESIGN/METHODS: The study used methodological triangulation to explore these issues within current practice. Focus groups were used to generate items for inclusion in the questionnaire. Questionnaire design was based on an importance-performance analysis. This procedure has been effective in developing health care marketing strategies. A stratified random sample of nursing staff (n=722) from the participating trusts received the questionnaire, eliciting a response rate of 172 (23.8%). RESULTS: Factor analysis provided a list of seven training categories in order of training need priority: information technology, awareness of roles, communications within seamless care, working across boundaries, professional issues, practice-related issues, delivery of patient/client care issues. There were no differences in nurses' training needs across NHS trusts. However, differences were highlighted for staff located in primary or secondary settings or working across the interface. CONCLUSIONS: Despite there being a vast range of training issues the majority of nurses appear to have a clear idea of their training needs for the provision of seamless care. A training programme required which targets the specific needs of nursing staff working at different positions across the primary/secondary care interface.     

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.     

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study

Few studies have explored how forensic mental health nurses can rebuild the therapeutic relationship following an episode of physical restraint in the acute forensic setting. In this study, we aimed to redress this gap in the literature by exploring with forensic mental health nurses the factors that enable or hinder the rebuilding of the therapeutic relationship following an episode of physical restraint. A qualitative study design was used to capture participants' experiences, views and perceptions of the therapeutic relationship following an episode of physical restraint in the acute forensic setting. Data were collected through individual interviews with forensic mental health nurses (n = 10) working in an acute forensic setting. Interviews were audio recorded, and transcribed verbatim and accounts were analysed using thematic analysis. Four themes were identified: ‘Building a Recovery Focused Therapeutic Relationship’; ‘Authoritarian Role’; ‘Inevitable Imbalance’; ‘Rebuilding the Therapeutic Relationship’; plus two sub-themes ‘Facilitators to rebuilding’ and ‘Barriers to rebuilding’. Findings suggest that an inevitable imbalance exists in building a recovery-focused therapeutic relationship and at times, is hindered by the authoritarian role of the forensic mental health nurse. Recommendations for changes in clinical practice and in upcoming policies should incorporate a dedicated debrief room and protected time for staff to debrief effectively following restraint. Routine post-restraint-focused clinical supervision would also be beneficial to mental health nursing staff.     

Measuring the workload of community mental health nurses: a review of the literature

The movement away from centralised awards along with the intensification of nursing work has provided an impetus for the Australian Nursing Federation to seek the inclusion of workload measurement tools into Enterprise Bargaining Agreements. This paper reports a review of literature undertaken to identify issues relating to workload measures developed for community mental health settings. The issues addressed include:a review of approaches to measuring workload; an evaluation of how applicable these approaches are to community mental health settings; a review of issues that need to be considered in applying a workload measurement tool to community mental health; and the identification of existing workload models for this setting. The paper concludes that activity based models which measure the work undertaken retrospectively are most appropriate for community mental health as they capture the less tangible aspects of community mental health nursing practice.     

Mental health emergency preparedness: the need for training and coordination at the state level

INTRODUCTION: The coordination and integration of mental health agencies' plans into disaster responses is a critical step for ensuring effective response to all-hazard emergencies. PROBLEM: In order to remedy the current lack of integration of mental health into emergency preparedness training, researchers must assess mental health emergency preparedness training needs. To date, no recognized assessment exists.The current study addresses this need by qualitatively surveying public health and allied health professionals regarding mental health preparedness in Kansas. METHODS: Participants included 144 professionals from public health and allied fields, all of whom attended one of seven training presentations on mental health preparedness. Following each presentation, participants provided written responses to nine qualitative questions about preparedness and mental health preparedness needs, as well as demographic information, and a program evaluation. Survey questions addressed perceptions of bioterrorism and mental health preparedness, perceptions about resource and training needs, as well as coordination of preparedness efforts. RESULTS: Overall, few respondents indicated that they felt their county or community was prepared to respond to an attack. Respondents felt less prepared for mental health issues than they did for preparedness issues in general. The largest proportion of respondents reported that they would look to a community mental health center or the state health department for mental health preparedness information. Most respondents recognized the helpfulness of interagency coordination for mental health preparedness, and reported a willingness to take an active role in coordination. CONCLUSIONS: The current study provides important data about the gaps regarding mental health preparedness in Kansas. This study demonstrates the present lack of preparedness and the need for coordination to reach an appropriate level of mental health preparedness for the state. These findings are the first step to implementing effective distribution of information and training.     

Violence in mental health settings: A systematic review

The introduction of smoke‐free policies is increasingly common in mental health settings, to improve health. However, a barrier to implementing smoke‐free polices is staff concern that violence will increase. We conducted a systematic review comparing the rates of violence before and after the introduction of smoke‐free policies in mental health settings. Two authors searched major electronic databases. We included studies reporting the prevalence of violence (verbal and/or physical or combined) before and after the introduction of a smoke‐free policy in a mental health, forensic, or addiction setting. We included 11 studies in the review. A narrative synthesis was used to describe the key results of each study. Six studies measured physical violence specifically; four reported a decrease or no change and two reported a short‐term increase. Five of these six studies also measured verbal violence; two found an increase, with one of the studies reporting that this increase was temporary. Three reported a decrease in verbal violence. A further five studies evaluated the rate of combined verbal and physical violence; four reported a decrease or no change and the other an increase. We conclude that the introduction of smoke‐free policies generally does not lead to an increase in violence. There is a need for more robust studies to support this finding. However, the conclusions from this review may be a step in reducing staff concerns.     

A qualitative study assessing mental health issues in two hospices in the UK

This study is a qualitative investigation into the experiences of assessing mental health issues by members of staff from two hospices in the UK. Nine individual interviews were held with doctors and nurses from the two hospices using semi-structured interviews. The research method used was grounded theory and the emerging data were analysed using the computer software Atlas.ti. The analysis was conducted around the four main research questions: 'How is mental health assessed in the hospices?', 'What are the staff members' feelings about doing these assessments?', 'How does assessment information inform clinical practice?' and 'What are the perceived training needs of staff?' The findings show that mental health is, to some extent, being assessed within these two hospices; however, no formal assessment strategy is in place. The majority of staff interviewed had very limited experience and/or training in the field of mental health and expressed a lack of confidence when dealing with mental health-related issues. A list of training needs has been identified. On the basis of these findings, recommendations have been made to improve the assessment procedures currently used within these two hospices.     

Multidisciplinary community mental health team staff's experience of a 'skills level' training course in cognitive analytic therapy

This study sought to explore community mental health teams' (CMHTs) experiences of receiving an innovative introductory level training in cognitive analytic therapy (CAT). CMHTs are important providers of care for people with mental health problems. Although CMHTs have many strengths, they have been widely criticized for failing to have a shared model underlying practice. Inter-professional training which develops shared therapeutic models from which to plan care delivery is, therefore, essential. We have been developing such a training based on the psychotherapeutic principles of CAT. Twelve community mental health staff (six mental health social workers and six community psychiatric nurses) were interviewed by an independent interviewer following the completion of the training programme. The interviews were analysed using a qualitative thematic analysis. The analysis revealed that the programme increased the participants' self-assessed therapeutic confidence and skill and fostered the development of a shared model within the team, although the training was also perceived as adding to workload. The results of this study suggest that whole-team CAT training may facilitate cohesion and also suggest that having some shared common language is important in enabling and supporting work with 'difficult' and 'complex' clients, for example, those with personality disorders. Further development of such training accompanied by rigorous evaluation should be undertaken.     

Effective Factors on Youth Satisfaction from Public Urban Spaces in Tehran

ABSTRACT

This evaluation study uses multiple methods to examine ways mental health issues are identified in juvenile justice residential placements. The study addresses essential characteristics of young males identified with mental health problems and differences between young people identified with mental health problems and the general residential population in a large, multi-site, nonprofit agency. The evaluation found that young males identified with mental health problems had several contacts with the social service network, the juvenile justice system and the mental health system before placement in the juvenile justice residential care setting. The evaluation raises concerns about identification mechanisms used to determine if residents have mental health problems, the responsiveness of residential program models, the need for post-residential community-based support, the importance of training residential staff, and the integration of mental health professionals into the intervention team.     

Barriers to Family Care in Psychiatric Settings

PURPOSE: To identify barriers to family care in psychiatric settings and to describe family and provider perspectives about what constitutes effective family care. DESIGN AND METHODS: A qualitative exploratory approach with focus groups. Seventy-eight people participated in 11 focus groups conducted with families, patients, and health professionals. FINDINGS: Families identified poor quality care, conflict with health professionals about treatment, and lack of a role for families in the treatment. African American families also identified isolation of their communities from the mental health care system. Adolescents emphasized their role as caregivers and their needs for support. Health professionals conveyed concerns about system-based barriers, professional practice-based barriers, and family-based barriers to care. Patients stated the need for their families to be better educated about mental illness. CONCLUSIONS: The lack of family care in psychiatric settings is a multifaceted problem. Current health policies do not show endorsement of a family care approach. Responses from families and health professionals indicated conflicting opinions about content of family care. Health professionals reported they often lacked training and resources to deal with complex family issues. Families believed that lengthy and intensive interventions were neither necessary nor desired to address their concerns. Family care can be improved by focusing on building rapport and communicating problems and concerns between families and health professionals.     

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.