Mental health: integrated network and family-oriented model for co-operation between mental health patients, adult mental health services and social services

Background. Co‐operation between mental health care units and the social services is important in the case of people with social problems who also suffer from mental health problems. However, participation of patients and their families in the treatment process, and co‐operation between them and the professionals, are also important. Communication between the professionals, patients and their family members, and the professionals is a crucial factor for co‐operation. Aims and objectives. The aim of this study was to elucidate the experiences and importance of co‐operation for the patients. The data consisted of interviews with 22 mental health patients who were also clients of municipal social services. Method. The grounded theory approach was used, focusing on the informants’ experiences of the integrated network and family‐oriented model for co‐operation. Results. The findings indicate the importance of the participation of patients and their social networks in psychiatric care or the treatment process. Meetings should be characterized by open and reflexive discussions with all participants’ points of view being included, so that fruitful co‐operation is possible. However, some negative experiences were also reported, all of which were connected with the professionals’ behaviour. Conclusions. Trust and honesty are essential elements in relations between professionals and psychiatric patients, but it cannot be assumed that they will develop naturally. It is the professionals’ responsibility to adjust their behaviour so that these elements can be created in a mutual process between patients and professionals. Multidisciplinary teams are a necessity in family‐oriented co‐operation between psychiatry and social services, and in a satisfactory caring process. Relevance to clinical practice. Nurses’ work is often individually oriented and nurses are ruled by routines in their work. The mental health caring process should be seen as a shared process between the patient, his/her human environment and professionals for which nurses need skills to their interaction with patients and their social network.     

Factors influencing nurse–patient interaction in the acute psychiatric setting: An exploratory investigation

Nurse–patient interaction in acute psychiatric in-patient facilities has been the subject of much discussion in the literature and remains a contentious issue. How and why nurses interact with patients in the acute care setting requires definition within the current dynamic environment of mental health service provision. Factors which impact on the manner in which nurses care for patients also require investigation. This article presents the findings of a collaborative research study that investigates factors that influence nurse–patient interaction in the acute psychiatric setting. Ten nurses on the study ward were given opportunity, through semi-structured interviews, to outline and describe the factors perceived to influence nurse–patient interaction. Factors identified as influencing interaction included the ward environment, something always comes up, nurses’ attributes, patient factors, instrumental support and focus of nursing. Issues which emerged from the study provide managers and clinical nurses with an opportunity for generating new possibilities for nurse–patient interaction. However, these issues must be addressed in a sensitive way that takes into account the complex and dynamic nature of acute care settings.     

Knowledge of the patient as decision‐making power: staff members' perceptions of interprofessional collaboration in challenging situations in psychiatric inpatient care

Challenging situations in psychiatric inpatient settings call for interprofessional collaboration, but the roles and responsibilities held by members of different professions is unclear. The aim of this study was to describe staff members' perceptions of interprofessional collaboration in the context of challenging situations in psychiatric inpatient care. Prior to the study taking place, ethical approval was granted. Focus group interviews were conducted with 26 physicians, ward managers, psychiatric nurses, and nursing assistants. These interviews were then transcribed and analysed using qualitative content analysis. Results described participants' perceptions of shared responsibilities, profession‐specific responsibilities and professional approaches. In this, recognising knowledge of the patient as decision‐making power was understood to be a recurring theme. This is a delimited qualitative study that reflects the specific working conditions of the participants at the time the study was conducted. The findings suggest that nursing assistants are the most influential professionals due to their closeness to and first‐hand knowledge of patients. The results also point to the possibility of other professionals gaining influence by getting closer to patients and utilising their professional knowledge, thus contributing to a more person‐centred care.     

Police referrals to a psychiatric hospital: Experiences of nurses caring for police‐referred admissions

Police are a major source of referral to psychiatric hospitals in industrialized countries with mental health legislation. However, little attention has been paid to nurses' experience of caring for police‐referred patients to psychiatric hospitals. This study utilized a Heideggerian phenomenological framework to explore the experiences of nine nurses caring for patients referred by the police, through semistructured interviews. Two major themes emerged from the hermeneutic analyses of interviews conducted with nurse participants: (i) ‘expecting “the worst” ’; and (ii) ‘balancing therapeutic care and forced treatment’. Expecting ‘the worst’ related to the perceptions nurse participants had about patients referred by the police. This included two sub‐themes: (i) ‘we are here to care for whoever they bring in’; and (ii) ‘but who deserves care?’ The second theme balancing therapeutic care and forced treatment included the sub‐themes: (i) ‘taking control, taking care’; and (ii) ‘managing power’. The study raises ethical and skill challenges for nursing including struggling with the notion of who deserves care, and balancing the imperatives of legislation with the need to work within a therapeutic framework.     

'They all said you could come and speak to us': patients' expectations and experiences of help on an acute psychiatric inpatient ward

Acute psychiatric inpatient care forms an integral part of mental health services. Few studies have focussed on the patient experience of acute care. Research into patient experience is increasingly important to policy and service development processes. Knowledge of patient experiences facilitates the development of nursing practice. The aim of the study was to gain insight into the experience of being a patient on an acute inpatient psychiatric ward. Thirteen participants were recruited from the acute ward. Unstructured interviews were used to gather narrative data of their experiences. Holistic analysis of the narratives was informed by Gee's socio-linguistic theories that meaning is linked to narrative structure. Reading of the holistic analyses yielded themes of help, safety and power running across the participants' experiences. The patient experience was characterized by dissonance between expectation and experience, the search for a nurse-patient relationship and the development of strategies to cope with being on the acute ward. This paper focuses on the theme of 'Help' where participants describe their expectation that they will receive help through the development of relationships with the nurses, and their experience of the barriers to this. In response, participants developed strategies to support each other.     

Collaboration in care and research

This article focuses on psychiatric mental health nursing care and research, with particular attention to collaboration with other health professionals in the area of geriatric mental health. Various components of the NIMH Task Force on Nursing report and recommendations are emphasized. These include research focused on: (a) improving the understanding, treatment, and rehabilitation of the mentally ill; (b) preventing mental illness and promoting mental health; (c) continuous care of persons who are acutely or chronically mentally ill or who are at risk for mental illness; (d) therapeutic interventions with ill persons or those at risk; and (e) the design, implementation, and evaluation of new and existing models of care delivery. An illustrative model of research in geriatric mental health nursing is presented. Particular attention is given to collaborative relationships developed by the primary nursing research team and the nursing staff in an acute care setting, colleagues providing nursing home care, and physician colleagues in geriatric mental health, gerontology, and neurology. Strategies to enhance collaboration and develop collegial relationships for better patient care are presented.     

Recovery‐oriented practice: Participant observations of the interactions between patients and health professionals in mental health inpatient settings

Despite an increasing attention towards recovery orientation in the mental health services, the provision of recovery‐oriented practice is challenged in the inpatient wards. Moreover, the existing research within this area is modest and we currently have limited knowledge of how recovery‐oriented practice is integrated into inpatient settings. A cornerstone of recovery‐oriented practice is the collaboration, patient involvement, and choices, particularly when deciding and planning treatment options. Thus, this ethnographic study aimed to explore how recovery‐oriented practice is reflected in the interactions between patients and health professionals around treatment in two mental health inpatient wards in Denmark. Participant observations were conducted in two mental health inpatient wards from November 2014 to January 2015. The Recovery Self‐Assessment scale inspired the observation guide and the initial data analysis. Field notes were analysed deductively and inductively using qualitative content analysis. One theme with four subthemes emerged showing that interactions were characterized by an ‘as‐if collaboration’ where ‘negotiating on limited grounds’ was an important feature of interactions, in which health professionals seemed to have superiority, acting on behalf of ‘competing demands’. Patients had to navigate in a field of ‘inconsistent guidance and postponed decisions’ and faced tendencies of ‘control and condescending communication’. The results suggest that recovery oriented values such as equal collaboration, choice and patients’ personal preferences are reflected rhetorically in the interactions between patients and health professionals. However, they are negotiated within organizational logics and often overruled by competing demands.     

The hidden contribution of the health care assistant: a survey-based exploration of support to their role in caring for the acutely ill patient in the general ward setting

butler-williams c. , james j. , cox h. & hunt j . (2010) Journal of Nursing Management 18, 789–795
The hidden contribution of the health care assistant: a survey-based exploration of support to their role in caring for the acutely ill patient in the general ward setting Aim To examine the feelings, support and feedback available to health care assistants (HCA) when caring for acutely ill ward patients. Background The role of the HCA continues to evolve with increased responsibility for patient care. Contextual issues that affect their contribution to acute care management of the ward patient have been given limited attention. Methods A survey of HCAs (n = 131) was conducted within two district general hospitals. Results There were a number of emotions and stressors associated with the care of acutely ill patients. While normal hierarchical systems were in place in order to obtain help HCAs additionally bypassed these normal channels. Support mechanisms included registered nurses, ward doctors, peers and family. Feedback regarding performance was limited. Conclusion HCAs play a significant role in the care of the acutely ill patient. Feedback mechanisms need to be developed and associated emotions recognized. Implications for nursing management HCAs support needs to be more evident and clinical feedback mechanisms need to be reviewed in order to improve care delivery.     

Encounters in a locked psychiatric ward environment

This focused ethnographic study aims at describing encounters in the healthcare environment on a locked psychiatric ward. It was carried out in Sweden on an acute psychiatric ward for patients with affective and eating disorders. Data were collected through participant observations and informal interviews, and analysed by qualitative content analysis. The result shows that the healthcare environment on this locked psychiatric ward offered a space for encounters between people, in a continuum from professional care to private meetings and social events. It included joy and friendship as well as unintentional insights into other patients' suffering. The characteristics of the encounters formed three themes: the caring relationship, the uncaring relationship and the unrecognized relationship. The caring and the uncaring relationship concerned relationships between staff and patients or their next of kin. These revealed contrasting qualities such as respect and flexibility as well as lack of respect and mistrust. The unrecognized relationship theme visualized the patients' relationships with each other and included both supportive and intrusive elements that were probably significant for the outcome of care. The unrecognized relationship contributes with new knowledge about conditions for patients in inpatient care, and indicates that the patients' relationships with each other merit greater attention.     

Once‐a‐week psychiatric ward round or daily inpatient team meeting? A multidisciplinary mental health team's experience of new ways of working

Evidence indicates that while service users are dissatisfied with current ward round practices, studies of how professionals experience this practice are sparse. This study highlights staff view of the once‐a‐week psychiatric ward round compared to a reformed ward round taking place every weekday. Interviews were conducted at one acute psychiatric ward in north‐west England. Our analysis revealed a core theme, ‘forming a new way of working’, which could be understood from three themes. The theme, ‘bound by tradition’, emphasized how the traditional ward round represented a double‐edged sword: it provided a safe structure, but it also highlighted a shared awareness of an urgent need to leave old ways of working behind. The process of change became discernable in the themes ‘juggling the change’ and ‘light at the end of the tunnel’, which showed that restructuring the traditional ward round was both possible and valued. We found that staff views on ward rounds are more complex than had been earlier understood, but new ways of working can be implemented, if the impact of tradition, the process of change, and the time to bed down are taken into account.     

Experiences of nursing care for patients who self-harm and suggestions for future practices: The perspectives of emergency care nurses

Self-harm is a major challenge in healthcare systems. Emergency department nurses provide care to numerous patients with self-harm injuries. Accordingly, nurse–patient interactions are vital to improve the physical and psychological outcomes of this complex patient group. Previous studies have proposed the establishment of improved teaching programs to increase the competence of emergency department nurses within mental health care; however, few studies have comprehensively investigated the experiences and suggestions for future nursing practices. Therefore, we gathered in-depth knowledge of Danish emergency department nurses' experiences caring for patients who self-harm and obtained their suggestions on future nursing practices. Ten semi-structured interviews were conducted to capture the nurses' individual perspectives. The scientific theory is based on phenomenology and hermeneutics. Interpretative phenomenological analysis was used, and three themes were identified: (i) importance of having the competences to establish a relationship in the acute phase; (ii) acute care from a biomedical perspective; and (iii) highlighting ideas for improved future practices. The emergency department nurses were aware of the importance of mental health care but found their competence and motivation situated in medical care. The nurses felt that they lacked skills to undertake in-depth mental care for patients who self-harm and that the healthcare system failed to help this group of patients. Based on these findings, rather than aiming at improving nursing skills, we suggest a close collaboration between the emergency and psychiatric departments to improve the quality of care for patients who self-harm. We also recommend organizational changes within the emergency department, such as the introduction of a so-called ‘social track’.     

Patients and nurses' perceptions of ward environmental factors and support systems in the care of suicidal patients

Aims. The aims of this paper are to present and discuss the findings that emerged from a qualitative study exploring nurses and patients’ views of the acute psychiatric ward (the context) and the type of care received (the intervening conditions). Background. The phenomenon of suicide and the nursing care of people who are suicidal have previously been investigated. However, literature demonstrates that there is a dearth of information exploring the importance of the ward context in the care of suicidal patients and the intervening conditions that are used by professionals in the care of suicidal patients. Method. Qualitative research using the grounded theory approach. Data collection and analysis. Fifteen patients who had either suicidal ideas or had attempted suicide and 15 psychiatric nurses were interviewed and observed. Data were analysed using open, axial and selective coding. Findings. A substantive theory of suicide‐nursing care was developed. For the purpose of this paper, the two categories that emerged in the ‘context’ element of the paradigm model are explored. They were: team working and the psychiatric ward environment. In addition, the four categories from the ‘intervening conditions’ are discussed. They were: nurses’ attitudes and beliefs have an effect on caring, barriers to caring, patients’ negative thoughts and feelings about the care provided and support systems. Conclusion. The findings indicated that the context of the ward environment and the intervening conditions used by nurses in the nursing care of suicidal patients helped to define some of the complex dynamics that impacted on the development of a therapeutic relationship within the practice of suicide‐nursing care. Relevance to clinical practice. Environmental factors as well as the nurses’ knowledge and skills and the type of support patients receive impact on the care of suicidal patients. These findings could help to enhance and advance suicide‐nursing care.     

Collaboration between Child and Adolescent Psychiatry and Child Welfare for Adolescent Girls with Multiple and Complex Needs: An Evaluation by Adolescents, (Step)Parents,and Professionals

Collaboration is put forward as a promising strategy for optimizing care delivery for the most vulnerable populations. The objective of this research was to explore how adolescents, (step)parents and professionals evaluate an intensive collaboration between a child welfare residential center and a child and adolescent psychiatric facility, aiming to optimize care delivery for adolescent girls with multiple and complex needs. This was done using in-depth interviews with nine adolescents and twelve (step)parents, along with focus groups with 44 professionals. Several benefits were identified: (1) care delivery is better tailored to meet individual needs; (2) access to mental health services and therapy implementation and follow-up are ameliorated; (3) focus on integration into society as well as on psychiatric support; (4) capacity and efficiency of care delivery is enhanced. Pitfalls were also mentioned: (1) preserving agency of clients; (2) maintaining the identity of the collaborating partners and openness to professionals outside the collaboration; (3) safeguarding continuity of care; (4) supporting individual professionals and teams. Findings illustrate the potential of collaboration in working with adolescents with multiple and complex needs. They highlight the importance of keeping the needs of adolescents and families as a main focus, while also being attentive to professionals’ needs.     

Therapeutic relationships,risk, and mental health practice

Despite significant changes to mental health services, nurses remain the professional group most likely to be in close contact with people who experience mental health problems. A core part of the contemporary identity of the mental health nurse is one who is able to provide acceptance and support for an individual's recovery through the therapeutic relationship. Yet there have always been some tensions with the mental health nursing role that can appear to challenge this relational focus. An increasing prominence of risk management in mental health care can position mental health nurses as responsible for enacting restrictions and has reignited interest in the role of mental health professionals in social control. This paper reports on one part of a multiple case study, which aimed to explore mental health professionals’ experiences of such tensions in the context of decision‐making. Interviews and observations were undertaken in acute ward and assertive outreach settings. Findings suggested that risk dominated decision‐making to such an extent it defined the way service users were understood and treated. A distant relationship between professionals and service users helped to create and maintain this situation. There needs to be a greater focus on service users’ subjective experiences in the decision‐making process to challenge the definition of people with mental health problems as risky.