Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.     

‘Walking the tightrope’: The role of peer support workers in facilitating consumers’ participation in decision‐making

In adult mental health services, the participation of consumers is essential. The aim of this study was to explore the challenges faced by peer support workers when involving mental health consumers in decision‐making about their care and the strategies they employed to overcome these challenges so as to improve mental health consumers’ participation in decision‐making and recovery. Semi‐structured individual interviews were conducted with six peer support workers currently employed in psychiatric hospitals and/or community mental health systems. Thematic analysis identified challenges related to role definition, power imbalance, doctor‐centric medical approaches to care, and lack of resources. Strategies to overcome these challenges that were reported, included the following: facilitating meaningful involvement for service users, appropriate use of the lived experience, building relationships and communication, promoting rights and advocacy, and promoting professionalism of peer support workers (PSWs). Nursing staff need ongoing support and education to understand and value the varied roles of PSWs and thereby empower PSWs to engage in enhancing consumer decision‐making. The roles of the PSWs should be viewed as complementary, and greater appreciation and understanding of roles would better support recovery‐oriented care.     

Exploring the meaning of recovery‐oriented care: An action‐research study

The present study describes participants' perspectives of the meaning of recovery‐oriented care in developing services for people with psychosocial disability associated with mental illness. Participants were involved in a 12‐month cooperative inquiry action‐research group from August 2012 to July 2013, with six consumers, four clinicians, and a carer. A major finding was the importance of the facilitation of dialogue that acknowledged the asymmetrical power differences between participants. Thematically‐analysed data identified an overarching global theme: ‘I want services to hear me’. The theme reflected a shared view that participation is important in service development. Actions included mapping the integration of consumer participation within a mental health service and developing workshops to support change. Addressing the asymmetrical power relationship inherent in traditional mental health design is important. Using participatory processes, structural discrimination is revealed, and tensions associated with clinical mental health services and psychiatric practice can be discussed. A partnership approach to service development enables the social determinants of health to be addressed more effectively, as well as supporting individual recovery. These approaches create the potential for genuine transformational change. Approaches that support coproduction and codesign have the potential to enable solutions.     

Mental health consumers' with medical co‐morbidity experience of the transition through tertiary medical services to primary care

Medical comorbidity in people with long‐term mental illness is common and often undetected; however, these consumers frequently experience problems accessing and receiving appropriate treatment in public health‐care services. The aim of the present study was to understand the lived experience of mental health consumers with medical comorbidity and their carers transitioning through tertiary medical to primary care services. An interpretative, phenomenological analysis approach was used, and semistructured, video‐recorded, qualitative interviews were used with 12 consumers and four primary caregivers. Four main themes and related subthemes were abstracted from the data, highlighting consumer's and carers’ experience of transition through tertiary medical to primary care services: (i) accessing tertiary services is difficult and time consuming; (ii) contrasting experiences of clinician engagement and support; (iii) lack of continuity between tertiary medical and primary care services; and (iv) Mental Health Hospital Admission Reduction Programme (MH HARP) clinicians facilitating transition. Our findings have implications for organisational change, expanding the role of MH HARP clinicians (whose primary role is to provide consumers with intensive support and care coordination to prevent avoidable tertiary medical hospital use), and the employment of consumer and carer consultants in tertiary medical settings, especially emergency departments.     

Investigating the validity and usability of an interactive computer programme for assessing competence in telephone‐based mental health triage

Telephone‐based mental health triage services are frontline health‐care providers that operate 24/7 to facilitate access to psychiatric assessment and intervention for people requiring assistance with a mental health problem. The mental health triage clinical role is complex, and the populations triage serves are typically high risk; yet to date, no evidence‐based methods have been available to assess clinician competence to practice telephone‐based mental health triage. The present study reports the findings of a study that investigated the validity and usability of the Mental Health Triage Competency Assessment Tool, an evidence‐based, interactive computer programme designed to assist clinicians in developing and assessing competence to practice telephone‐based mental health triage.     

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.     

Research involving mental health consumers and carers: a reference group approach

Policy changes within the mental health system are creating an increasing expectation that service providers increase the opportunities for consumer and carer participation in the planning, delivery and evaluation of mental health services. If they are to reflect this change in philosophy, researchers have an obligation to ensure the involvement of consumers and carers, above and beyond involvement as a participant in all relevant mental health research. This paper describes the establishment and function of a reference group, established to guide and assist with the conduct of a research project examining the experiences of consumers and carers with psychiatric disability support services. The formation and operation of, and the valuable contribution made by, the reference group is discussed.     

Saudi service users’ perceptions and experiences of the quality of their mental health care provision in the Kingdom of Saudi Arabia (KSA): A qualitative inquiry

This paper presents, as part of a larger mixed‐methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi‐structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users’ health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self‐awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay’s ‘Cultural Originality’ as well as contemporary examples of Goffman’s mortification of the self.     

Addressing the support needs of families during the acute hospitalization of a parent with mental illness: A narrative literature review

Hospitalisation of a parent with acute mental health problems impacts the consumer, their extended family/carers and children. Mental health nurses are at the forefront of promoting recovery for consumers in an acute inpatient setting. Recovery‐oriented care can include provision of family‐focused care which supports recovery of the parent‐consumer and their family members and contributes to prevention of intergenerational mental illness. The aim of this narrative literature review was to explore existing knowledge regarding the experiences, care and support needs of parent‐consumers, their family members/carers and children during the parent's acute mental health hospitalisation. It also aims to explore existing knowledge about the practices of mental health nurses providing care to this consumer group, to inform future healthcare practice and strengthen parent, child and family outcomes. Nineteen published studies addressed the review questions. In the context of hospitalisation, the majority of research regarding parenting with a mental illness is focused on mothers. Parents reported experiencing stigma during their hospitalisation. Separation from children was a concern for parents and their extended family, but admission provided an opportunity for the parent to receive treatment and for the family to receive support. Mental health nurses did not always identify parental status on admission. When parental status was identified, nurses reported issues regarding logistics and practicalities of using family rooms, children visiting the unit, and their own professional knowledge and organisational support regarding familyfocused care. Implications for practice are identified, highlighting how mental health nurses can develop their practice to support the recovery of parent‐consumers.     

Identifying the core competencies of mental health telephone triage

Aims and objectives. The primary aim of this study was to identify the core competencies of mental health telephone triage, including key role tasks, skills, knowledge and responsibilities, in which clinicians are required to be competent to perform safe and effective triage. Background. Recent global trends indicate an increased reliance on telephone‐based health services to facilitate access to health care across large populations. The trend towards telephone‐based health services has also extended to mental health settings, evidenced by the growing number of mental health telephone triage services providing 24‐hour access to specialist mental health assessment and treatment. Mental health telephone triage services are critical to the early identification of mental health problems and the provision of timely, appropriate interventions. In spite of the rapid growth in mental health telephone triage and the important role these services play in the assessment and management of mental illness and related risks, there has been very little research investigating this area of practice. Design. An observational design was employed to address the research aims. Methods. Structured observations (using dual wireless headphones) were undertaken on 197 occasions of mental health telephone triage over a three‐month period from January to March 2011. Results. The research identified seven core areas of mental health telephone triage practice in which clinicians are required to be competent in to perform effective mental health telephone triage, including opening the call; performing mental status examination; risk assessment; planning and action; termination of call; referral and reporting; and documentation. Conclusions. The findings of this research contribute to the evidence base for mental health telephone triage by articulating the core competencies for practice. Relevance to clinical practice. The mental health telephone triage competencies identified in this research may be used to define an evidence‐based framework for mental health telephone triage practice that aims to improve the quality, consistency and accuracy of telephone‐based mental health triage assessment.     

Consumer's perceptions of Recovery‐oriented mental health services: An Australian case‐study analysis

Recovery approaches to health care now feature in the mental health policies of many Western countries. There are, however, continuing challenges to the operationalization of these approaches. This study aimed to identify the nature of these challenges for a public mental health service organization located in a major urban center in southeastern Australia, where Recovery‐oriented services have been implemented; and to develop recommendations to address these challenges. These aims were achieved by asking mental health consumers about their experiences of the implementation of Recovery‐oriented services. Research participants described an uncertainty in health professionals and consumers alike about how to practice within a Recovery model, with many health professionals taking a “hands off” approach in the name of Recovery, rather than working in partnership with consumers and other stakeholders, including the community managed organizations. Solutions to these challenges included more targeted, practice‐focused education for consumers and health professionals, with this education provided by consumer representatives. Insights derived from this research add to the growing body of evidence related to the implementation of Recovery‐oriented services in Western countries.     

Physical health nurse consultant role to improve physical health in mental health services: A carer's perspective

The physical health of people diagnosed with a mental illness is significantly poorer in comparison with the general population. Awareness of this health disparity is increasing; however, strategies to address the problem are limited. Carers play an important role in the physical health care of people with mental illness, particularly in facilitating navigation of and advocating in the health care system. A specialist physical health nurse consultant position has been suggested as a way to address the physical health care disparity and limited research available suggests that positive outcomes are possible. In the present study, a qualitative exploratory research project was undertaken, involving in‐depth interviews with people identifying as mental health carers. Two focus groups and one individual interview were conducted involving a total of 13 carers. The resulting data were analyzed thematically. Views and opinions about the proposed physical health nurse consultant (PHNC) position were sought during these interviews and are reported in this paper. Two main sub‐themes were evident relating to characteristics of this role: reliability and consistency; and communication and support. Essentially carers expressed a need for support for themselves and consumers in addressing physical health concerns. Successful implementation of this position would require a consistent and reliable approach. Carers are significant stakeholders in the physical health of consumers of mental health services and their active involvement in identifying and tailoring services, including development of the physical health nurse consultant must be seen as a priority.     

Laying new foundations for 21st century community mental health services: An Australian perspective

While there has been a significant increase in investment in community mental health in Australia since the advent of the National Mental Health Strategy in the early 1990s, there has been little guidance on service design and delivery. This has led to a growing diversity of approaches and concern about the adequacy of care with repeated calls for a system overhaul. Consumers and carers have very largely been absent from decision‐making about service design and development which has led to a system primarily designed by healthcare professionals. However, with the emergence of recovery as a core principle in mental health, it is time for consumers and carers to be centrally engaged in co‐designing services with service providers. This raises the question of whether dominant service delivery models – such as the growth of specialist teams/services, the changing balance between profession‐specific and generic case management roles in multidisciplinary teams, and the separation of inpatient from community care – will prevail. Contentious issues in these three service delivery areas are outlined to stimulate debate and highlight the pressing need for national guidance on the configuration of community mental health services. Building on the lessons learned from the first National Mental Health Strategy, we outline a proposal for a co‐designed National Framework for Community Mental Health Services to guide the delivery of care in a way which satisfies the aspirations of consumers, carers, and mental health professionals alike.     

Comparison of a co‐produced mental health service to traditional services: A co‐produced mixed‐methods cross‐sectional study

This study investigates the differences between a co‐produced experimental mental health centre and traditional day centres. For this purpose, we used a collaborative and mixed‐method approach in two complementary studies: (i) a quantitative cross‐sectional study designed to compare users' hospitalization rates and their use of psychiatric medications and (ii) a qualitative study designed to explore and document the experienced differences between co‐produced and traditional services. In the quantitative cross‐sectional study, surveys were administered to 37 users of one co‐produced mental health service and to 40 users of traditional mental health services. A negative binomial regression analysis was performed to examine the relationships between predictors and users' hospitalization rates. After adjusting for the potential confounders, users of the co‐produced centre reported a 63.2% reduced rate of hospitalizations compared with users of traditional mental health services (P = 0.002). Furthermore, 39% of users of the co‐produced centre reported a reduction or even withdrawal from psychiatric medications against 22% of the comparison group (P = 0.036). In the qualitative study, six main differences emerged from a thematic analysis of a large user‐led focus group. In the participants' experiences, the co‐produced service focused on (i) parity and respectful relationships, (ii) people's strengths, (iii) freedom, (iv) psychological continuity, (v) social inclusion, and (vi) recovery orientation. Our research provides empirical evidence concerning the ‘preventive aspect’ of co‐produced mental health services. Additionally, new insights into how different stakeholders, particularly users of co‐produced mental health services, experience the differences between co‐produced and traditional mental health services are provided.     

Implications of evidence‐based practice for mental health nursing

The introduction of evidence‐based practice (EBP) and the hierarchical approach to evidence it engenders within research and evaluation has aroused controversy in the mental health professions. The aim of this paper is to present a critique of EBP with a specific relationship to mental health nursing. It will be argued that in its current form, EBP presents a potential impediment to the facilitation of consumer participation in mental health services and to the recovery model. The need for the consumer voice and the importance of the lived experience of mental illness are not readily reconciled with a strong scientific paradigm that promotes detachment and objectivity. The importance of evidence in contemporary mental health care will also be acknowledged and discussed in light of the current climate of increased consumer knowledge, fiscal constraint, and extensive social criticism of mental health‐care services. The current approach to EBP requires reconstruction to support the consumer‐focused nature of mental health nursing, and to facilitate the implementation of a recovery model for mental health care.     

Practice standards to improve the quality of family and carer participation in adult mental health care: an overview and evaluation

ABSTRACT:  Mental health services are required to involve family, carers, and service users in the delivery and development of mental health services but how this can be done in routine practice is challenging. One potential solution is to prescribe practice standards or clear expectation relating to family involvement. This paper describes practice standards introduced to an adult mental health service and a study that aimed to evaluate the impact of the standards on practice. Hospital and community files were audited before and after the introduction of standards for evidence of participation and surveys of carers and consumers relating to the quality of participation were undertaken. Increases in documented carer participation were found, particularly in relation to treatment or care planning. The expressed needs relating to participation varied in hospital and community settings. The majority of carers and service users were satisfied with their level of participation. The introduction of practice standards is an acceptable, inexpensive, and feasible way of improving the quality of family and carer participation, but gains may be modest.     

Consumers in mental health service leadership: A systematic review

Contemporary mental health policies call for greater involvement of mental health service consumers in all aspects and at all levels of service planning, delivery, and evaluation. The extent to which consumers are part of the decision‐making function of mental health organizations varies. This systematic review synthesizes empirical and review studies published in peer‐reviewed academic journals relating to consumers in leadership roles within mental health organizations. The Cochrane Library, Medline, and PsycINFO were searched for articles specifically analysing and discussing consumers’ mental health service leadership. Each article was critically appraised against the inclusion criteria, with 36 articles included in the final review. The findings of the review highlight current understandings of organizational resources and structures in consumer‐led organizations, determinants of leadership involvement, and how consumer leadership interacts with traditional mental health service provision. It appears that organizations might still be negotiating the balance between consumer leadership and traditional structures and systems. The majority of included studies represent research about consumer‐run organizations, with consumer leadership in mainstream mental health organizations being less represented in the literature. Advocates of consumer leadership should focus more on emphasizing how such leadership itself can be a valuable resource for organizations and how this can be better articulated. This review highlights the current gaps in understandings of consumer leadership in mental health, including a need for more research exploring the benefits of consumer leadership for other consumers of services.     

Determining the effectiveness of mental health services from a consumer perspective: part 2: barriers to recovery and principles for evaluation

The routine use of standardized outcome measures has been introduced to assess the effectiveness of mental health service delivery throughout Australia. The use of these measures has been criticized for failing to reflect those aspects of treatment consumers consider to affect their recovery. This is the second of a two-part paper. Its aim is to explore the views of consumers regarding factors that impede recovery and to explore the principles that ideally should underpin the evaluation of mental health services. Focus group interviews were conducted with consumers of mental health services (n = 16) from one rural and one metropolitan mental health service in Victoria, Australia. This paper presents the findings, pertaining to aspects of mental health services that pose barriers to recovery. The main themes to emerge were: staffing issues; hearing the person not the illness; lack of safety and security; and, isolation. The main themes to emerge regarding the evaluation of mental health services were: consumer involvement; peer support and more responsive care and treatment. The views of participants suggest that the effective evaluation of mental health services requires an increased focus on the views and opinions of consumers in order to develop more responsive mental health services.     

Family and carer participation in mental health care: perspectives of consumers and carers in hospital and home care settings

It is widely accepted that family and carer participation in adult mental health care is desirable. However, rarely is service development informed by representative opinions of both carers and service users. This study took place in the context of a larger project to introduce and evaluate practice standards relating to family participation. The aim of this paper is to explore the perceptions of service users and carers to carer participation in adult mental health services. One hundred and twenty-nine service users and 86 family members recruited via hospital and community settings completed a survey which addressed obstacles to family participation, perceived benefits of participation and areas for improvement. Many service users and family were entirely satisfied with existing levels of family participation. Different needs for information, support and the nature of participation in mental health care are highlighted in acute hospital and community settings. Across settings, the provision of support and accessing services were identified as the most useful aspects of family participation. Meaningful carer and family participation in mental health care should proceed from respectful connection with carers and be informed by need which will vary depending on setting and circumstances.