Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.     

The person in health care policy development

Objective The objective of this article is to explore the rationale for involvement of persons in health care policy in western countries, and to examine evidence of the difference public involvement can make. Methods The information is drawn from research and reports on changes in health care policy towards greater democratization of decision making. Conclusions Strong reasons have been put forward for wider public involvement in health care policy, and some evidence is now available that involvement is popular with stakeholders and can improve services, though it is a complex intervention needing complex strategies of evaluation.     

Attitudes of mental health professionals towards service user involvement

Patient‐centred care and user involvement in healthcare services are much emphasised globally. This study was the first step in a multicentre research project in Finland to improve service users' and carers' opportunities to be more involved in mental health services. The aim of the study was to assess attitudes of professionals towards service user involvement. The data were collected via an online questionnaire from 1069 mental health professionals in four hospital districts. Altogether, 351 professionals responded. Data were analysed using appropriate statistical methods. According to the results, attitudes of healthcare professionals were more positive towards service users' involvement in their own treatment than in other levels of services. There were also differences in gender, age groups, working places and experiences in the attitudes of professionals concerning service users' involvement in their own treatment. These should be taken into account in the future when planning education for mental health professionals. In spite of governmental guidance on service user involvement and the growing body of knowledge of the benefits associated with it, change in attitudes towards user involvement is slow. Special attention should be paid to the attitudes of professionals working in inpatient care and of those with less working experience.     

Mental health policy and mental health service user perspectives on involvement: a discourse analysis

AIM: This paper is a report of an exploration of the concept of service user involvement in mental health nursing using a discourse analysis approach. BACKGROUND: Service user involvement has come to be expected in mental health nursing policy and practice. This concept, however, is often applied somewhat ambiguously and some writers call for a clearer understanding of what service users actually want. METHOD: A Foucauldian discourse analysis was conducted in 2005, examining literature and health policies published by the United Kingdom government and service users. The discursive perspectives of both were explored and conceptual themes were generated from the data. FINDINGS: Concepts occurring within government discourse include language relating to service users, the notion of service user involvement and power. Concepts from the service user discourse include power, change and control, theory, policy and practice, and experiential expertise. Differences in perspectives were found within these themes which distinguished government from service user discourses. Greater flexibility in ideas and perspectives was demonstrated by service users, with a seemingly greater range of theoretical underpinnings. CONCLUSION: Greater awareness is needed of the significance of language, of how subtle inferences may be drawn from the rhetorical language of policies, of how these might affect the involvement of service users, and of the implications for the role of mental health nurses. Nurses need to be aware of these tensions and conflicts in managing their practice and in creating a mental health nursing philosophy of 'involvement'. If true 'involvement' is to ensue, nurses may also need to consider the transfer of power to service users.     

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

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

Teamwork in primary care mental health: a policy analysis

Aim This paper reports a policy analysis conducted to examine the potential impact of recent mental health policy on team working in Primary Care Mental Health in England. Method An analysis of relevant policy documents was conducted. From an original selection of 49 documents, 15, which had significant implications for Primary Care Mental Health Teams, were analysed thematically. Findings There were no clear guidelines or objectives for Primary Care Mental Health Teams evident from the policy analysis. Collaborative working was advocated, yet other elements in the policies were likely to prevent this occurring. There was a lack of clarity concerning the role and function of new professions within Primary Care Mental Health Teams, adding further uncertainty to an already confused situation. Conclusion This uncertainty has the potential to reinforce professional barriers and increase the current difficulties with team working. Implications to nursing managers An analysis of recent policy contributes to our understanding of the context of care. The lack of clarity in current health policy presents a significant challenge for those managing primary care mental health teams. Team working is likely to improve if targets, processes and responsibilities are made clearer.     

Specialist educational intervention for acute inpatient mental health nursing staff: service user views and effects on nursing quality

AIM: This paper reports a study to evaluate the impact of an innovative 18-day educational intervention for acute ward-based mental healthcare nursing staff on documented quality of nursing care and on service user views of that care. BACKGROUND: There are grave concerns internationally about the quality of inpatient mental health care for people with acute psychiatric problems. It is claimed that specialist educational courses are needed to improve these services. However, whilst such courses may lead to positive learning outcomes for participants, the impact on the actual care of service users is unknown. METHOD: An uncontrolled before-and-after evaluation of three acute mental health wards from different United Kingdom National Health Service trusts was carried out. Quality of nursing care was evaluated by extracting documentary evidence from service user records, assessed by two independent researchers according to predefined quality criteria. The views of a purposive sample of mental health service users, currently receiving services from the three designated wards, were ascertained by semi-structured interview. RESULTS: Both documentary evidence and service user views revealed some important baseline deficiencies in the quality of care offered at the study sites. Following the educational intervention, statistically significant improvements were observed in the quality of care planning, initial assessments and the provision of therapeutic care. No statistically significant changes were observed in the quality of risk assessments, medication management or external agency involvement. CONCLUSIONS: Education can have an impact on nursing care but may not be sufficient alone to change mental healthcare practices on acute inpatient wards in the radical manner demanded by policymakers and service user lobby groups. Educational interventions need to be implemented in conjunction with organizational changes that are specifically designed to maximize the opportunities presented by a newly skilled and positive workforce.     

Service user views and expectations of UK-registered mental health nurses: a systematic review of empirical research

OBJECTIVES: To review national (UK) literature in order to (i) examine service user and carer views of UK-registered mental health nurses; (ii) identify the diversity of populations from which these views have been collected; (iii) assess the methodological rigour of the current knowledge base and (iv) evaluate the extent to which service users and carers have been involved in the development and execution of this work. This paper reports only on service users' views. DESIGN: Systematic review. DATA SOURCES: Electronic and evidence-based databases, reference checking and hand searching of key academic journals, national policy and user/carer organisational websites. REVIEW METHODS: Two reviewers independently undertook study eligibility judgements and data extraction. Eligible studies were sub-classified according to service setting (inpatient/residential, community/non-residential or mixed/unspecified). Each study was assessed against key quality criteria. Data were synthesised in a narrative format. RESULTS: One hundred and thirty two studies were included in the review. The majority were small-scale academic studies biased towards white, adult service users. Few studies provided evidence of user collaboration. Service users regard mental health nursing as a multi-faceted role delivering practical and social support alongside more formal psychological therapies. Service users report inadequate information provision, poor inter-professional communication and a lack of opportunities for collaborative care. Service users perceive inpatient mental health nurses as particularly inaccessible. CONCLUSIONS: UK-registered mental health nurses should be equipped with both therapeutic clinical skills and generic skills associated with relationship building, engagement and communication. Future research should be conducted in collaboration with service users and include clear and effective mechanisms for the dissemination and implementation of research findings. In particular, the views of children and adolescents, the elderly and black and minority ethnic groups, currently under-represented in research, should be examined.     

A short report on the prevalence of mental health disturbance in children and young people: Interpretations and implications for the mental health care of adolescent women

In this short report, some recent statistics of mental disorder prevalence in young people are presented and discussed from a gender perspective. It is suggested that girls with mental health problems might experience difficulty in having their needs met within services which may still embody significant elements of paternalism and where psychodynamic phenomena may impact on care delivery. Findings may have implications for practitioners involved in child and adolescent mental health care.     

Trends in mental health: implications for advanced practice nurses

PURPOSE: To examine current trends in mental health care for vulnerable populations and suggest how advanced practice nurses (APNs) can incorporate mental health care into primary care practice. DATA SOURCES: Original research and evidence-based clinical articles, government publications, and professional practice guidelines. CONCLUSIONS: Vulnerable populations, such as racial and ethnic minorities, adults with chronic mental illness, the elderly, the incarcerated, and those living in rural areas have long been ignored as recipients of quality, integrated health care services. There is a compelling need for APNs to participate in the integrated delivery of physical and mental health care to all Americans, especially to vulnerable populations. IMPLICATIONS FOR PRACTICE: Under the umbrella of advanced practice nursing, a variety of nurse practitioners (NPs) and clinical nurse specialists (CNSs) can offer a holistic approach to the provision of evidence-based health care in a wide variety of settings to an array of vulnerable and underserved people. By serving on provider panels, partnering with consumer groups, and advocating for the unmet health needs of vulnerable populations, APNs can have a positive impact on the health care delivery system.     

The integration of comprehensive psychiatric/mental health care into the primary health system: diagnosis and treatment

This research study was funded by the Health Systems Trust in Cape Town through the University of Natal in Durban. OBJECTIVES. The objectives of this study were to teach primary health care nurses to diagnose and treat common psychiatric conditions, to refer those patients whom they cannot handle, and to evaluate the implementation of these functions in their primary health care practice. METHODS. Twenty nurses from six clinics in one province of South Africa were trained, and implementation was studied. History taking, diagnosis, pharmacological treatment and referral were studied through record reviews. Record reviews were done by two independent psychiatrists, who achieved an inter-rater reliability of 0.68. RESULTS. Record reviews showed that at the end of the project nurses could take substantially complete psychiatric histories in 89% cases, five axis diagnoses were correct in 63% of cases, and when STAT medication was prescribed it was appropriate in 92% of cases. Appropriate long-term medication was prescribed in 60% of cases. ETHICAL ISSUES. Permission was obtained from the provincial office, the Municipal Offices and participating clinics. Informed consent was obtained by the registered nurses from all participating clients. LIMITATIONS. The sample for the clinics was not representative of all clinics in the Eastern Cape but a representation of rural-urban settings sampled from 20 clinics in a region. The sample of consumers was convenient and may not represent the client population in each clinic. For this reason the findings may not be a true reflection of the entire region, and generalization of the findings should be made at the utmost discretion of the reader.     

Nursing and politics: a South African perspective

The purpose of this paper is to provide a general introduction to politics, and to describe some political changes which have affected the rendering of multidisciplinary health care services in the Republic of South Africa since 1994. Political issues which will be addressed include: changed provincial borders; opening up of the Republic of South Africa's international borders; increased emphasis on primary health care services; enhanced international involvement of the Republic of South Africa; changes in the statutory bodies governing the nursing profession; and changed legislation affecting health care workers. Political know-how is essential for professional survival. Unless nurses in the Republic of South Africa collaborate proactively as a united group representing the largest proportion of health care professionals in the country, the nursing profession and nursing education might become irrelevant to the political realities of the country and its people. Unless nurses can succeed in engaging in successful political debates and in negotiating their rights, they might become an increasingly voiceless, faceless and powerless female profession in the Republic of South Africa. However, politically knowledgeable nurses may help to ensure that the people will get the nurses and the nursing care they deserve, whilst the nurses will enjoy the benefits to which they are entitled, including market-related salaries.     

Psychiatric nurses' views on criteria for psychiatric intensive care: acute and intensive care staff compared

AIM: To explore and investigate differences between the views of qualified nurses working in psychiatric intensive care units (PICUs) and acute care wards on which patients are appropriate for PICU care. BACKGROUND: Previous research on the area of psychiatric intensive care highlights the great differences that exist in all aspects of service provision, from unit size and staffing levels to treatment approaches and physical environment. One of the most common areas of controversy is the type of client behaviour that warrants admission to the PICU. METHOD: Structured interviews of 100 qualified nursing staff (in the London area, England) working on either acute or PICU wards were used to gather data on appropriate and inappropriate referral to PICUs. Comments made during the course of the interviews were also collected and subjected to content analysis. FINDINGS: There was evidence to support the hypothesis that acute ward staff considered patients suitable for PICU care at a lower level of risk than PICU staff thought appropriate. In comparison to acute ward nurses, those working in PICUs attended to a broader range of factors when considering suitability for admission to PICU. Appropriate reasons for transfer fell into five groups: risk to others; risk of intentional harm to self; risk of unintentional harm to self; therapeutic benefit from the PICU environment; and legitimate acute ward care problem. Inappropriate reasons for transfer fell into four groups: low risk to others and/or self; illegitimate acute admission care problems; patient belongs elsewhere; policy issues. CONCLUSION: The study opens up a range of issues not previously studied in relation to the use of PICUs and the intricate relationship of this use with the available acute care wards and other services. These findings and their implications for the care of acute and disturbed psychiatric patients are discussed.     

Enhancing oral health for better mental health: Exploring the views of mental health professionals

The association between oral health, self‐esteem and quality of life is well established yet there is limited research on the impact of addressing the poor oral health of people living with mental health disorders. Greater consideration is warranted on how enhancing oral health in the course of mental healthcare might reduce the burden of a person's ill health. The role of mental health professionals is important in this regard yet uncertainty persists about the role these providers can and should play in promoting oral health care for people with mental health disorders. This qualitative study explored the issue of oral health and mental health with community based mental health professionals in Perth, Western Australia. It examined their views on the oral health status and experiences of their clients, and the different and alternative ways to improve access to care, knowledge and preventative regimens. Findings indicated participants’ ambivalence, reluctance and lack of training in raising oral health issues, despite its acknowledged importance, indicating a siloed approach to care. Findings offer an opportunity to reflect on whether a more integrated approach to oral health care for people with mental health disorders would improve health outcomes.