Nurse-Patient Interaction in Acute Adult Inpatient Mental Health Units: a Review and Synthesis of Qualitative Studies

Mental health nurses work with acutely unwell patients, and the busy setting is characterised by unpredictable events. This paper is a report of a review conducted to identify, analyse and synthesize research in adult acute inpatient mental health units, which focused on nurse-patient interaction. Several electronic databases were searched using relevant keywords to identify studies published from 1999-present. Qualitative studies published in English were included if they specifically investigated nurse-patient interaction in acute inpatient care in adult settings. Eighteen studies were included (23 papers). Findings were grouped into the following six categories: 1) sophisticated communication; 2) subtle discriminations; 3) managing security parameters; 4) ordinary communication; 5) reliance on colleagues; and 6) personal characteristics. These studies of acute inpatient mental health units reveal that nurse communication involves interpersonal approaches and modalities that exemplify highly developed communication and personal skills designed specifically for this challenging setting. Further quality research should focus on the conditions that enable the development of therapeutic interactional skills and the relationship of these skills to the nuanced context in which they are practiced.     

Ethnographic Research into Nursing in Acute Adult Mental Health Units: A Review

Acute inpatient mental health units are busy and sometimes chaotic settings, with high bed occupancy rates. These settings include acutely unwell patients, busy staff, and a milieu characterised by unpredictable interactions and events. This paper is a report of a literature review conducted to identify, analyse, and synthesize ethnographic research in adult acute inpatient mental health units. Several electronic databases were searched using relevant keywords to identify studies published from 1990-present. Additional searches were conducted using reference lists. Ethnographic studies published in English were included if they investigated acute inpatient care in adult settings. Papers were excluded if the unit under study was not exclusively for patients in the acute phase of their mental illness, or where the original study was not fully ethnographic. Ten research studies meeting our criteria were found (21 papers). Findings were grouped into the following overarching categories: (1) Micro-skills; (2) Collectivity; (3) Pragmatism; and (4) Reframing of nursing activities. The results of this ethnographic review reveal the complexity, patient-orientation, and productivity of some nursing interventions that may not have been observed or understood without the use of this research method. Additional quality research should focus on redefining clinical priorities and philosophies to ensure everyday care is aligned constructively with the expectations of stakeholders and is consistent with policy and the realities of the organisational setting. We have more to learn from each other with regard to the effective nursing care of inpatients who are acutely disturbed.     

Health Service Inpatient Units for People with Intellectual Disabilities and Challenging Behaviour or Mental Health Problems

Background As institutions for people with intellectual disabilities have been replaced with community services, health care provision has developed to provide assessment and treatment, low and medium secure units for people with challenging behaviour or mental health problems. These include both public and private sector provision. Little is known about these services. The aim of this study was to describe the characteristics of the services studied and to compare the different types of service. Methods A survey was carried out of National Health Service (NHS) and independent sector (IH) health settings providing specialist inpatient services for people with intellectual disabilities. Data were collected on setting and patient characteristics, staffing and management and care processes and outcomes. Results Services were very unevenly distributed across England. There were differences between NHS and IH settings. IH assessment and treatment units were bigger, had higher occupancy and lower staff ratio. In all three types of unit, IH units had fewer visits to patients, used more seclusion, physical restraint and had more locked areas. They had more complaints in more services from users and (for assessment and treatment units and low secure units only) from relatives. In low secure units, they had more adult protection referrals. On the other hand, IH units used fewer agency staff in assessment and treatment units (though more in medium secure units) and provided more appraisals, more visits from commissioners, more consultations with GPs and dentists and more use of whistleblowing procedures by staff. A quarter of people in NHS assessment and treatment units had finished treatment but had no plan for discharge. Conclusions Further research is required to determine the reasons for differences observed between IH and NHS units. The large number of people who have finished treatment emphasizes the importance of developing housing in the community with sufficiently skilled support. The large number of patients in low secure services raises the question whether this type of service is recreating the intellectual disability institutions which government policy intends to close.     

Establishing a Collaborative Care CBT Milieu in Adolescent Inpatient Units

Cognitive Therapy and Research - On average, psychotherapy delivered on inpatient units produces clinical outcomes with smaller effect sizes than the same treatments in outpatient settings. The...     

Restriction and Control: The Perceptions of Mental Health Nurses in a UK Acute Inpatient Setting

In the United Kingdom there has been growing unease over standards of care and treatment in acute inpatient psychiatric services. Although recent reforms have declared nurses as pivotal to the social transformation required, few accounts inform modernisers about the reality of social systems, relations, and events in modern acute psychiatric services. This qualitative study explores the situation of nurses working in acute inpatient psychiatric services. It particularly describes the social control elements that continue to influence working norms. Five nurses were interviewed and texts of these interviews were transcribed and analysed using content analysis. As a further source of data, documents were interpreted to illuminate social mechanisms. Issues of objectivity, validity, and reliability were considered throughout. Ethical issues were considered throughout and approval for the study was gained from the appropriate Research Ethics Committee. Social control functions portrayed by day-to-day rituals and operating norms emerged as a central theme in the findings. Social control is a prominent working norm. This is described through activities of observation, surveillance, and managing “difficult” behaviours. Therapeutic relationships present as a paradox to the control assumed. Implications of these findings are discussed.     

Piloting Violence and Incident Reporting Measures on one Acute Mental Health Inpatient Unit

During May, 2006, on one acute mental health inpatient unit, nursing staff evaluated each patient three times a day (i.e., once each nursing shift) using the Broset Violence Checklist (BVC). Associated data were collected using the Staff Observation and Aggression Scale-Revised (SOAS-R) if an adverse incident occurred. At the end of the data collection period, the nursing staff were asked to complete a short questionnaire anonymously to evaluate how useful they had found the instruments. N = 93 patients were admitted to the unit during the month of study. Seven incidents were reported using the SOAS-R. A slight trend was noted for higher BVC score in aggressive patients. A potential high occurrence of underreporting on incidents was observed. There was limited feedback data from nursing staff at the end of the study, but the responses received were encouraging for continued use of the instruments in practice. The pilot study fulfilled its purpose in two ways. First, it allowed staff on the unit to experience using structured instruments to support their practice. Second, it allowed an opportunity to raise awareness of potential underreporting and tolerance of aggression on the unit.     

Mental Health Recovery Through "Art Therapy": A Pilot Study in Portuguese Acute Inpatient Setting

The main aims of the study are to a) evaluate the effectiveness of a three session program of “art therapy” on changing emotional indicators (depression, anxiety, stress, and psychological well-being) in individuals with mental illness and b) analyze the meanings attributed to creative self-expression. We performed a pre-experimental mixed approach study, with a pretest–posttest design, with twelve Portuguese male subjects, admitted to an acute psychiatry unit. The instruments used were Depression, Anxiety and Stress Scale [DASS-21]; and Ryff Scales of Psychological Well-Being [SPWB – 18] and a semi-structured interview. Comparison of the pre- and posttest indicated improvement in anxiety, stress, self-acceptance, purpose of life, and overall psychological well-being. The categories resulting from the thematic analysis of the interviews revealed the usefulness of the program in the participant recovery process. This type of psychosocial intervention in specialized clinical practice in Mental Health Nursing minimizes the disease’s impact in an organizational culture that should increasingly be oriented toward recovery.     

The Use of Restrictive Measures in an Acute Inpatient Child and Adolescent Mental Health Service

There are significant issues associated with the use of restrictive measures, such as seclusion and restraint, in child and adolescent mental health care. Greater understanding of how restrictive measures are used is important for informing strategies to reduce their use. In this brief report we present a 12-month audit (1/1/2010–31/12/2011) of the use of restrictive measures (seclusion, physical restraint) in one child and adolescent acute inpatient mental health unit in Australia. The study highlights the need for continued efforts to reduce the use of restrictive measures in child and adolescent mental health services.     

Influencing Undergraduate Nursing Students' Attitudes Toward Mental Health Nursing: Acknowledging the Role of Theory

Most research designed to explore undergraduate nursing students' attitudes towards mental health nursing tends to uphold clinical experience as the decisive factor, with much less attention paid to the theoretical component. This paper presents the findings of a state-wide study conducted with undergraduate nursing students in Victoria, Australia. A pre- and post-test design was used to measure students' attitudes toward people with a mental illness and toward mental health nursing and their sense of preparedness for mental health practice. A questionnaire was administered at two time points; the first time point was following completion of the mental health nursing theoretical component, and the second was following the completion of clinical experience. An additional scale was added at the second time point to evaluate students' opinions about their clinical placement. The findings indicated significantly different attitudes and opinions depending on the university students attended. The amount of theory undertaken in the course accounts for some, but not all, of this variance. However, generally the students taking courses with a larger theoretical component tended to demonstrate higher scores (suggestive of more favourable attitudes) on all of the subscales, and that these differences were sustained following the completion of the clinical placement. These findings suggest that the amount of theory students receive in mental health nursing may be more influential than the relevant literature suggests.     

A Major Stream in Mental Health in Undergraduate Nursing Programmes: Identifying the Benefits and Acknowledging the Innovation

The literature demonstrates the problems mental health nursing has faced in securing sufficient graduate nurses to meet current and projected workforce needs. Deficiencies in educational preparation have been identified as a significant contributing factor. A major stream in mental health nursing has been introduced into undergraduate Bachelor of Nursing programmes as one strategy to address this problem. To-date, 11 streams have been introduced into Australian universities and no evaluations of the impact of these initiatives have been published as yet. This qualitative research was undertaken to explore the implementation and outcomes of major streams. In-depth telephone interviews were undertaken with participants from 10 universities, to explore their experiences with and opinions of this initiative. This paper specifically addresses the perceived benefits. Qualitative data analysis revealed many benefits to the major in promoting the value of, and encouraging interest in mental health nursing for undergraduate students. Four main themes were identified: (1) benefits to students; (2) benefits to the university; (3) benefits to industry; and (4) innovative approaches to education. The findings suggest the major in mental health nursing can contribute to addressing workforce problems in mental health nursing.     

Learning to Observe in Context: Child and Adolescent Inpatient Mental Health Assessment

On child and adolescent inpatient psychiatric units, nursing staff have 24-hour exposure to patients, an excellent vantage point for observing behavior in a variety of situations and interpersonal contexts. How staff members respond to milieu behaviors depends in part on their judgment of what prompted a youngster's response and his/her ability to process the event and control the attendant emotions. To assess such aspects of a child or adolescent's presentation requires that staff appraise not just the presenting behavior but the patient's information-processing and affect-regulation abilities. One way this developmental knowledge can be embedded in practice is through assessment guides that contain observation cues for key issues related to how children/adolescents think, feel, and behave. This article sets down the rationale for the content and organization of such inpatient nursing assessment guides and suggestions for their dissemination to the unit staff.     

Mental Health of the African Girl Child: Challenges for Nurses

In this paper, the ecological systems theory of child development is used as the framework for exploring research on the development of African children, especially girl children. The special problems faced by children and the challenges this raises for nurses also are described in this paper.     

Military Mental Health Stigma Challenges: Policy and Practice Considerations

All providers are challenged to reduce mental health stigma through awareness of service member mental health needs and advocacy. Individually stigmatizing perceptions and beliefs that interfere with mental health care become internalized into a service member's identity, persisting in veterans after military service. Years to decades can pass before a service member seeks professional help for psychological problems, and, therefore, practitioners need to be sensitive to subtle indications of distress. Furthermore, care that supports military members is culturally sensitive, innovative, and taps into resources for evidence-based interventions that maximize function and quality of life for service members and their families.     

Challenges Highlighted During Peer Supervision by Mental Health Nurses and Social Workers Recently Trained as Case Managers in Sweden

This study looked at 13 mental health nurses and social workers who were recently trained as case managers (CMs) and the work-related challenges they faced in community mental health services. Data were collected during ten peer supervisions sessions. Participants expressed pride and enthusiasm about their new function as CMs, but they also acknowledged that their new position meant they had to confront existing systems and posed several challenges, including organizational hindrances, economic prerequisites, nominated administrators, role function, and model fidelity. We conclude that the existing organizations seemed to be unprepared to hold and facilitate more person-centered approaches, such as designating CMs. The model fidelity is important, but has to be flexible according to clients’ daily state.