Acknowledging communication: a milieu-therapeutic approach in mental health care

Title. Acknowledging communication: a milieu‐therapeutic approach in mental health care Aim. This paper is a report of a study to develop milieu therapists’ acknowledging communication in their relationships with patients. Background. Gunderson’s therapeutic processes in milieu therapy have come into use in a broad range of mental health contexts in many countries. Research in nursing indicates that validation needs a more concrete development for use in clinical work. Methods. Schibbye’s theory, ‘Intersubjective relational understanding’, formed the theoretical foundation for a participatory action research project in 2004–2005. The data comprised the researcher’s process notes written during participation in the group of group leaders every second week over a period of 18 months, clinical narratives presented by participants in the same group, and eight qualitative interviews of members of the reflection group. Findings. The core concept in acknowledging communication, mutuality, was described as inter‐subjective sharing of feelings and beliefs in a respectful way. Participants presented their process of development as a movement from knowing what was best for the patient (acknowledging patients as competent persons, a milieu‐therapy culture based on conformity), to appreciating diversity and stubborn talk, to reflective wondering questions. Misunderstanding of acknowledgement occurred, for instance, in the form of always being supportive and affirmative towards patients. Conclusion. The concrete approaches in acknowledging communication presented in this article could be a fruitful basis for educating in and developing milieu therapy, both for nursing and in a multi‐professional approach in clinical practice and educational institutions. Future research should focus on broader development of various areas of acknowledging communication in practice, and should also include patients’ experiences of such approaches.     

The challenges of mental health care reform for contemporary mental health nursing practice: delivery of nursing care

This ethnographic account of mental health nursing in a 22-bed acute inpatient facility in New South Wales, Australia, uncovered cultural meaning and cultural realities associated with the delivery of nursing care within the context of current challenges, demands, and influences brought about by service reforms. The findings demonstrate that mental health nurses have been responsive to changes brought about by the reforms. The ability of nurses to readily identify service gaps in their everyday practice provides them with the opportunity to develop strategies to respond to workplace challenges. As such, findings of the study contribute to current discussions concerning acute inpatient mental health nursing practice.     

Creating a nursing development unit in a dementia care context

Keatinge D, Scarfe C. International Journal of Nursing Practice 1998; 4: 120–125 Creating a nursing development unit in a dementia care context This paper describes the process through which a Nursing Development Unit (NDU) was created in a 29-bed unit in which nurses care for severely demented residents. The question about whether or not ethics clearance is required for the development phase of NDUs is discussed, and the framework in which to develop the NDU described. The benefits of using Participatory Action Research as the basis for undertaking a continuous process of reflection and change is highlighted. It is also suggested that two key elements necessary for NDUs are that they are ‘owned’ by the staff who work in them and that they are supported by senior management of the organisations in which they exist.     

User involvement in mental health nursing practice: rhetoric or reality?

Following the review of mental health nursing, nurses need to address the dilemma of providing empowering care in a climate of increasing control and stigma. This paper discusses tile background to, and significance for nursing, of the 'user movement' in the UK. A current 'explosion' of user groups does not imply that these form a homogeneous group, nor that they share similar perspectives. Consultation and involvement mean little if unmatched with action. This may be constrained by the 'market' in which the 'true power' is held by the budget holder, and by stigmatizing policy imperatives claimed to be in the public interest. Self-advocacy may be legitimized by the desire to prevent providers 'speaking out'. These difficulties may, however, provide convenient excuses for inaction. A new professional identity may be found in forging political alliances with users, in which a reappraisal of traditional boundaries may go some way towards reducing the stigma surrounding mental health problems.     

Rethinking mental health nursing education in Australia: a case for direct entry

Desperate times call for creative solutions. The mental health workforce shortage has created an opportunity to rethink current and future education and training needs in order to prepare competent and compassionate practitioners to meet the changing demands of consumers and their carers requiring mental heath treatment and support. This article urges consideration of an undergraduate direct entry mental health programme similar to that of midwifery or the nursing foundation/mental health branch programmes of the UK.     

Developments in mental health nursing: a critical voice

This paper examines stances that are being adopted in relation to the current and future direction of mental health nursing practice. The argument is made that mental health nursing is being pushed into a direction that is essentially positivistic and narrow in its focus, stating that the current hegemony of thinking which dictates that our primary focus of concern should be with individuals suffering from severe or recurring mental illness, allied with the drive towards 'evidence based practice' is symptomatic of wider issues that should be of concern to all parties interested in the issue of mental health care. The authors examine the context and rationale for these developments from socio-political, philosophical and ethical viewpoints, highlighting that their logical outcome is the exclusion of individuals from the right to health care and question the motives underpinning what could be considered a fundamental shift in the provision of mental health services. The argument is then advanced that caution should be adopted by mental health nursing services before abandoning what Gournay (1994) described as 'redundant ideologies' and that a broader view of mental health nursing action should be accommodated. The validity of trying to account for mental nursing action in quantifiable and biomechanistic terms is questioned and an alternative paradigm of accounting for such action is suggested.     

Developing a concept analysis of control for use in child and adolescent mental health nursing

The need to help children and young people with significant mental health problems develop a sense of personal control in their everyday lives, in a manner which does not endanger themselves or others, was recognized by nurse practitioners working in an English regional multidisciplinary child and adolescent mental health residential unit. A concept analysis of control was undertaken and used to develop a framework for analysing control. This deductive framework was modified iteratively by nurses who developed new knowledge from a qualitative exploration of current practice and the application of the evolving framework to practice problems. The paper describes this process and highlights three main findings: (i) the evolving attributes of the concept analysis helped nurses steer a course through the complexities of practice; (ii) the research highlighted and enabled nurses to confront the paradoxical nature of control; (iii) the process enabled nurses to recognize the mutuality of feelings aroused simultaneously when both the nurse and the child are challenged to maintain personal control.     

Changing the mental health nursing culture: the nursing clinical development unit approach

Developments in nursing as a profession have been accompanied by a perceived need to increase the relevance of research to nursing practice. The increased exposure to research in nursing curricula and the development of nursing academia has had little impact on either the conduct of clinical research or its utilization within the work place culture. Nursing Clinical Development Units (NCDU) were established with the view to overcoming some of these barriers through partnerships between academia and the clinical field. The aim of NCDU is to strive for improved patient outcomes. Education and research activities should be directed to achieve this patient-orientated outcome. The aim of this paper is to describe the NCDU program introduced by the Centre for Psychiatric Nursing Research and Practice (CPNRP) in Melbourne, Victoria. The way in which the program is designed to facilitate the relationship between CPNRP and the clinical field with the aim of contributing to improved patient outcomes will be emphasized. An evaluation of the program to date suggests that such links will be strengthened, and that this partnership will contribute to a greater involvement in clinically based research.     

Participative mental health consumer research for improving physical health care: An integrative review

People with mental illness have a significantly lower life expectancy and higher rates of chronic physical illnesses than the general population. Health care system reform to improve access and quality is greatly needed to address this inequity. The inclusion of consumers of mental health services as co‐investigators in research is likely to enhance service reform. In light of this, the current paper reviews mental health consumer focussed research conducted to date, addressing the neglect of physical health in mental health care and initiatives with the aim of improving physical health care. The international literature on physical healthcare in the context of mental health services was searched for articles, including mental health consumers in research roles, via Medline, CINAHL and Google Scholar, in October 2015. Four studies where mental health consumers participated as researchers were identified. Three studies involved qualitative research on barriers and facilitators to physical health care access, and a fourth study on developing technologies for more effective communication between GPs and patients. This review found that participatory mental health consumer research in physical health care reform has only become visible in the academic literature in 2015. Heightened consideration of mental health consumer participation in research is required by health care providers and researchers. Mental health nurses can provide leadership in increasing mental health consumer research on integrated care directed towards reducing the health gap between people with and without mental illness.     

Models of mental health care for older adults: a review of the literature

Aim.  This paper reviews literature that draws on models of mental health care for older adults.
Background.  It is predicted that as a consequence of the aging of the population the incidence of mental health disorders, common in older populations, will also rise. Many such disorders can be successfully managed if detected early. Assessment and management requires collaboration between health professionals who are skilled and educated in the management of older adults with mental illness and the use of models of care appropriate to this population.
Results.  The paucity of research in this area is demonstrated.
Conclusion.  The need for mental health nurses to challenge current models of mental health care for older adults is identified so that they take on an expanded and developed specialist role in care of older adults with mental illness.     

A role for mental health nursing in the physical health care of consumers with severe mental illness

There is extensive international evidence that people with severe mental illness have a lower standard of physical health than the general population. This leads to higher morbidity and mortality rates. Many of the causes for this poor physical health are modifiable. Yet the physical needs of this consumer group are neglected by healthcare systems in Australia, and elsewhere. While medical specialists are clearly integral to remedying this, nurses are well placed to play a key role in focused prevention and early intervention in the physical well-being of consumers with mental health problems. This paper outlines the specifics on how mental health nurses can be sensitized, prepared and empowered to help turn this serious health issue around. In particular, mental health nurses could be trained in and then utilize a new physical health check and response system in the UK (called the Health Improvement Profile) if adapted for use within Australia. This profile will be briefly introduced, and then its value to improving health care discussed.     

Integration of theory and practice in learning mental health nursing

This article describes an action research project that aimed at a better integration of theory and practice in the education of mental health nursing students. Two partners, an institute of nursing and health care and a university hospital, collaborated to develop a new educational programme for mental health nursing. The blocks of theoretical studies were implemented simultaneously with practical training, and the theory content was taught by nursing teachers as well as by nurse practitioners who worked on the teaching wards. In addition, the students had their own personal nurse-preceptors on the wards. The nurse managers were responsible for the educational level of the teaching wards and the director of nursing planned the teaching arrangements together with the nursing teachers. In all, the project involved over 50 different actors and several researchers. The results are encouraging: all the participants - students, preceptors, nurse managers and nursing teachers - found the project rewarding and they want to continue to develop and improve the level of teaching and learning in mental health nursing education. All the participants grew and developed professionally during the project.     

Placing physical activity in mental health care: a leadership role for mental health nurses

The wide-ranging benefits of physical activity for consumers with mental illness are acknowledged within the mental health nursing field; however, this is not commonly translated to practice. The primary aim of this paper is to argue that mental health nurses are well positioned to, and should, provide leadership in promoting physical activity to improve the quality of care for people with mental illness. Topics addressed in this paper include the relationship between physical activity and both physical and mental health, the views and experiences of consumers with physical activity, the efficacy of physical activity interventions, the attitudes of nurses to physical activity as a component of care, barriers to a physical activity focus in care for mental illness, and the role of mental health nurses in promoting physical activity. There is a clear and important relationship between physical activity and mental health. Mental health nurses are well positioned to encourage and assist consumers to engage in physical activity, although they might lack the educational preparation to perform this role effectively.     

Implementing a major stream in mental health nursing: Barriers to effectiveness

Changes to the educational preparation of the nursing workforce in mental health continue to have profound effects on the availability of sufficient numbers of skilled graduates willing to work in this field. The longevity of the problem has focused attention on possible solutions. Introducing a major stream in mental health nursing in undergraduate Bachelor of Nursing programmes was proposed and supported as a potentially beneficial strategy, adopted by some Australian universities. Despite the promise invested in this strategy, systematic evaluations to determine the effectiveness or otherwise of this approach were not initiated. A qualitative exploratory study was undertaken with Australian universities, which had implemented the major stream, regarding their experiences and observed outcomes. In‐depth interviews were conducted with a mental health nurse academic from each university. The barriers to the effectiveness of the major in mental health nursing are the specific focus of this paper. Thematic data analysis revealed three main barriers: clinical placements, lack of support from other academics, and integrated curricula. These barriers substantially limited the effectiveness of this strategy – in some instances, leading to the programme's termination – and must be assertively addressed to maximize the potential of the major in mental health nursing.     

Promoting mental health nursing: employing undergraduate nursing students as assistants in mental health

The difficulty in attracting graduates of nursing programmes into mental health nursing (MHN) remains an ongoing challenge. Moreover, it is frequently claimed that undergraduate nursing students do not always regard MHN favourably for future employment. Although undergraduate nurses are employed as assistants in nursing (AIN) in mental health settings, there is no published research exploring their role, the career trajectory into MHN, or its effectiveness as a recruitment strategy. In this paper, we draw on the literature to delineate factors that might contribute to the desire of AIN to work in MHN. Nine factors were identified: acceptance by nurses, fitting in with the culture, managing the workload, developing a realistic appraisal of the effectiveness and limits of psychiatry, constructive learning from direct interpersonal interactions with clients, practising communication skills, being supported in a structured way, working with positive role models, and the overall quality of the employment setting. A comprehensive understanding of these factors can enhance the experience of undergraduate nursing students working as AIN, and potentially increase recruitment into MHN.     

Facilitators and barriers in implementing clinical nursing assessment in mental health care for older people: A multimethod approach

With the aging of the population and the growing prevalence of dementia, specialized and collaborative nursing care is paramount in this area. To ensure better quality care, it is necessary to use effective and context‐specific processes to implement evidence‐based practices and more specifically clinical nursing assessment. This study aimed to identify and describe factors that may influence the implementation of clinical nursing assessment in mental health care for older people. The Consolidated Framework for Implementation Research was employed to guide evaluation in the pre‐implementation phase in the specific context of mental health care for older people. Using a multimethod approach, interviews, focus groups, and a quantitative survey were conducted with a non‐probability convenience sample. A total of 39 hospital nurses (registered nurses and head nurses) were interviewed. Analysis yielded five main factors, notably three barriers and two facilitators. Barriers include a lack of general nursing culture, deficiencies in leadership, and difficulties in communication and collaboration. Facilitators comprise team cohesion and the perceived benefits of the study.