Clinical indicators as measures of mental health nursing standards of practice in New Zealand

This paper discusses the utility of Consumer Notes Clinical Indicators (CNCI) as a means to monitor mental health nursing clinical practice against the Australian and New Zealand College of Mental Health Nurses' (ANZCMHN) Standards of Practice for mental health nursing in New Zealand. CNCI are statements describing pivotal mental health nursing behaviours for which evidence can be found in the nurses' case notes. This paper presents 25 valid and reliable CNCI that can be used to monitor mental health nursing practice against the ANZCMHN's Standards of Practice for mental health nursing in New Zealand. The bicultural clinical indicators were generated in focus groups of Maori and non-Maori mental health nurses, prioritized in a three-round reactive Delphi survey of expert mental health nurses and consumers, pilot tested, and applied in a national field study. This paper reports the development and validation of the CNCI, for which achievement is assessed by an audit of the nursing documentation in consumer case notes. The CNCI were tested in a national field study of 327 sets of consumer case notes at 11 District Health Board sites. The results of the national field study show wide variation in occurrence of individual indicators, particularly in the areas of informed consent, information about legal rights, and provision of culturally safe and recovery-focused care. We discuss the implications of using the CNCI to assess the professional accountability of mental health nurses to provide quality care. Recommendations are made regarding the application of the clinical indicators and future research required, determining appropriate benchmarks for quality practice. The CNCI could be adapted for application in other mental health nursing and other mental health professional clinical settings.     

The New Zealand development and trial of mental health nursing clinical indicators--a bicultural study

This paper describes the development and validation of bicultural clinical indicators that measure achievement of mental health nursing practice standards in New Zealand (ANZMCHN, 1995, Standards of practice for mental health nursing in New Zealand. ANZCMHN, Greenacres). A four-stage research design was utilised including focus groups, Delphi surveys, a pilot, and a national field study, with mental health nurses and consumers as participants. During the national field study, consumer files (n=327) from 11 District Health Boards, and registered nurses (n=422) completed an attitude questionnaire regarding the regularity of specific nursing and service activities. Results revealed a variation in the mean occurrence of the clinical indicators in consumer case notes of 18.5–89.9%. Five factors with good internal consistency, encompassing domains of mental health nursing required for best practice, were derived from analysis of the questionnaire. This study presents a research framework for developing culturally and clinically valid, reliable measures of clinical practice.     

Mental health nursing standards for Australia: a review of current literature

ABSTRACT:  The expanding role of the mental health nurse brings new challenges and rewards. To support this, nationally adopted, formalized standards of practice are required. Currently, the Standards of Practice for Mental Health Nurses in Australia published by the Australian and New Zealand College of Mental Health Nurses in 1995 provide a guide for mental health nurses working in Australia. While these standards have played a role in supporting mental health nurses, they have not been widely adopted. This report reviews the current literature on standards for practice and describes an evidence-based rationale as to why a review and renewal of these is required and why it is important, not just for mental health nurses but to the field of mental health in general.     

Nurse- and midwife-led trials in Australia and New Zealand: Scoping review protocol

BackgroundResearch led by nurses or midwives has the potential to successfully address current issues in clinical care. High-quality randomised controlled trials are needed to inform evidence-based practice; however, nursing and midwifery research has commonly been nonexperimental. Two connected scoping reviews of nurse- and midwife-led randomised controlled trials within Australia and New Zealand will be conducted to highlight potential research directions and identify resources for future research.AimThe purpose of the two reviews is to map the number and types of randomised controlled trials led by nurses or midwives within Australia and New Zealand.MethodsThe concept of interest is randomised controlled trials with a lead principal investigator holding nursing or midwifery credentials. The lead principal investigator must report an institutional affiliation in Australia or New Zealand, and the trial must recruit at a minimum of one site in Australia or New Zealand. Searches for academic literature will be conducted using Pubmed, Emcare, and Scopus. Sources for grey literature will include the Australian New Zealand Clinical Trials Registry, and grant outcomes published by the National Health and Medical Research Council, Medical Research Future Fund, and Health Research Council of New Zealand. Data analysis and presentation will be conducted separately for each review.DiscussionThese reviews will comprehensively map the experimental research activity of nurses and midwives within Australia and New Zealand and highlight potential research directions. From this, strategies to facilitate high quality nurse- and midwife-led trials can be developed, which are vital for informing evidence-based practice.     

A survey of role stress, coping and health in Australian and New Zealand hospital nurses

BACKGROUND: Previous research has identified international and cultural differences in nurses' workplace stress and coping responses. We hypothesised an association between problem-focused coping and improved health, emotion-focused coping with reduced health, and more frequent workplace stress with reduced health. OBJECTIVES: Test the above hypotheses with Australian and New Zealand nurses, and compare Australian and New Zealand nurses' experience of workplace stress, coping and health status. PARTICIPANTS AND SETTINGS: Three hundred and twenty-eight New South Wales (NSW) and 190 New Zealand (NZ) volunteer acute care hospital nurses (response rate 41%) from randomly sampled nurses. DESIGN AND METHOD: Postal survey consisting of a demographic questionnaire, the Nursing Stress Scale, the WAYS of Coping Questionnaire and the SF-36 Health Survey Version 2. RESULTS: Consistent with hypotheses, more frequent workplace stress predicted lower physical and mental health. Problem-focused coping was associated with better mental health. Emotion-focused coping was associated with reduced mental health. Contrary to hypotheses, coping styles did not predict physical health. NSW and NZ scored effectively the same on sources of workplace stress, stress coping methods, and physical and mental health when controlling for relevant variables. CONCLUSIONS: Results suggest mental health benefits for nurses who use problem-solving to cope with stress by addressing the external source of the stress, rather than emotion-focused coping in which nurses try to control or manage their internal response to stress. Cultural similarities and similar hospital environments could account for equivalent findings for NSW and NZ.     

The development of a professional practice audit questionnaire for mental health nursing in Aotearoa/New Zealand

ABSTRACT:  This paper reports the three-stage development of a professional practice audit questionnaire for mental health nursing in Aotearoa/New Zealand. In Study 1, clinical indicator statements ( n  = 99) generated from focus group data, which were considered to be unobservable in the nursing documentation in consumer case notes, were included in a three-round Delphi process. Consensus of ratings occurred for the mental health nurse and academic participants ( n  = 7) on 83 clinical indicator statements. In Study 2, the clinical indicator statements ( n  = 67) that met importance and consensus criteria were incorporated into a questionnaire, which was piloted at a New Zealand mental health service. The questionnaire was then modified for use in a national field study. In Study 3, the national field study, registered mental health nurses ( n  = 422) from 11 New Zealand District Health Board mental health services completed the questionnaire. Five categories of nursing practice were identified: professional and evidence-based practice; consumer focus and reflective practice; professional development and integration; ethically and legally safe practice; and culturally safe practice. Analyses revealed little difference in the perceptions of nurses from different backgrounds regarding the regularity of the nursing practices. Further research is needed to calibrate the scores on each clinical indicator statement with behaviour in clinical practice.     

The role of second health professionals under New Zealand mental health legislation

The development of generic statutory roles in mental health care has been the subject of discussion by New Zealand nurses for the past decade. One such role is that of second health professional in judicial reviews of civil commitment. Issues identified by New Zealand nurses have also been raised in England, where it seems that nurses are likely to assume the role of Approved Mental Health Worker under English mental health law. A survey of mental health nurses found that few had received any preparation for the role of second health professional and 45% did not feel adequately prepared for the role. Some of these issues are reflected in a New Zealand inquiry which resulted in the Ministry of Health developing a written report form for second health professionals. However, the form has the potential to reduce the mental health nursing role to a narrow legal role. Statutory roles such as that of second health professional challenge mental health nurses to critically reflect on the conceptual and ethical basis of their practice. While traditional concepts such as therapeutic relationships and advocacy need to be reviewed in light of these changes, nurses need to be vigilant in articulating the moral and clinical basis of their roles. The development of guidelines for he second health professional role is suggested as a way of supporting clinical practice in this area.     

Mental health nurses’ contributions to community mental health care: An Australian study

Australian mental health policy is focused on providing mental health care in the community setting and community mental health teams provide services to clients in a shared model with primary care. The historical literature reports that community mental health nurses’ experience high levels of stress and are often allocated the most complex and challenging clients managed by the team. Yet information on their specific roles remains limited. This paper reports on research conducted at one Australian public mental health service to identify the components of the community mental health nursing role and to quantify the time nurses spent in each component during the study period. Six focus groups were conducted with community mental health nurses to identify their perceived role within the team. Data analysis identified 18 components of which 10 were related to direct clinical contact with clients and eight covered administrative and care coordination activities. A data collection tool based on the findings of the focus groups was designed and nurses recorded workload data on the tool in 15‐min intervals over a 4‐week period. Seventeen nurses collected 1528 hours of data. Internal coordination of care was identified as the top workload item followed by clinical documentation and national data collection responsibilities supporting the complexity of the community mental health nursing role. The high rating attached to the internal coordination of care role demonstrates an important contribution that community mental health nurses make to the functioning of the team and the delivery of quality mental health care.     

Workplace resilience and emotional labour of Australian mental health nurses: Results of a national survey

Emotional labour is a form of adversity faced by mental health nurses in the context of their workplace interactions. Frequent exposure to emotional adversity can negatively impact mental health nurses’ biopsychosocial well‐being, workplace relationships, and performance. Workplace resilience is a dynamic interactive process within and between the person and their environment that promotes positive adaptation to adverse events and restores well‐being. Workplace resilience could be a protective process that helps mental health nurses positively adapt to workplace emotional adversity. This study aimed to investigate Australian mental health nurses’ workplace resilience and emotional labour and explore the relationship between them. A national cross‐sectional online survey comprising the Resilience at Work and Emotional Labour scales was completed by registered nurses (n = 482) working in a mental health role or setting across Australia. There was a strong negative relationship between resilience and the emotional labour strategy of surface acting. A positive association between resilience, frequency of emotional labour, and clinical supervision was also found. These findings point to a potential link between mental health nurses’ skills of cognitive reframing, and emotional and behavioural regulation needed to effectively manage their emotions and remain therapeutic in interpersonal interactions. Clinical supervision may be a key strategy in supporting mental health nurses’ resilience. Further investigation of workplace individuals’ internal and external resources, and organizational resources, supports, and strategies that can promote and strengthen mental health nurses’ well‐being is needed.     

Law and policy in relation to the use of seclusion in psychiatric hospitals in Australia and New Zealand

This paper discusses legal issues associated with the seclusion of acutely disturbed patients in psychiatric hospitals in Australia and New Zealand. There continues to be great variation in opinion and operational definition as to whether seclusion is a medical treatment, nursing intervention and management tool, or merely a form of situational restraint. Reflecting this lack of clarity, mental health acts and policies concerning the regulation and practice of seclusion lack consistency and focus across geographical boundaries and jurisdictions. Australian and New Zealand legislation and institutional policy is discussed in order to shed light on the contemporary issues highlighted by this controversial nursing practice. Mental health professionals must continue to review the practice of seclusion and to actively promote the use of acceptable alternatives. In addition nurses and other mental health professionals have a responsibility to understand current legislation and policy frameworks and to influence change where this is necessary to ensure the best practice possible in their clinical area.     

Staff Burnout –a Comparative Study of Metropolitan and Rural Mental Health Nurses within Australia

This article will present the findings of a research study that investigated the extent to which mental health nurses employed within rural and metropolitan areas of Australia are affected by burnout, using the Maslach Burnout Inventory (MBI) and a demographic questionnaire. The study also examined whether the Maslach Burnout Inventory (MBI) was a valid measure of mental health burnout within the Australian context and culture or alternatively, in what ways it needed to be refined? A cross-sectional study of mental health nurses (n = 319) from the states of New South Wales, Victoria, Queensland and Western Australia was undertaken. The 22-item Maslach Burnout Inventory (MBI) was used to measure burnout and a demographic questionnaire utilising a cluster sampling, cross-sectional design survey method, was used to gather the data. The study found that gender and level of qualification were the two major factors that showed any significance, where males experienced a higher level of depersonalisation on the frequency and intensity sub-scale scores of the MBI and that the more qualified a nurse, the greater the level of depersonalisation they experienced. These results were true for participants in both rural and metropolitan settings within Australia. Age was the third most influencing factor in terms of emotional exhaustion, where younger participants (under 30) reported higher levels of emotional exhaustion. Younger male mental health nurses experienced higher levels of depersonalisation.     

The remarkable (Disappearing Act of the) mental health nurse psychotherapist

The aim of this Australian based qualitative study was to better understand key drivers for mental health nurses to undertake training in psychotherapy, and how these capabilities are integrated into their clinical practice. Open ended reposes from a national survey of 153 mental health nurses were supplemented with data from 12 semi‐structured interviews of nurses with rich experience of integrating psychotherapy and mental health nursing capabilities. Key findings emerging from the thematic analysis were that mental health nurses are providing uniquely holistic psychotherapeutic services to consumers with often complex conditions, despite overtly hostile clinical and policy contexts. These often very well qualified mental health nurse psychotherapists are different to the traditional identity of either a nurse or psychotherapist. Recommendations from the findings of this study are that where appropriately qualified, mental health nurses be granted eligible provider status for existing Medicare funding items. Finally, training and building foundational capabilities in psychotherapy is highly recommended for all mental health nurses.     

Mental health‐related learning needs of clinicians working in Australian emergency departments: A national survey of self‐reported confidence and knowledge

Objective: To identify the mental health‐related learning needs of doctors and nurses working in Australian EDs. Methods: A purpose‐designed survey was developed, and face validity was verified by 12 doctors and nurses. A cross‐sectional survey of a national sample of nurses and senior doctors (registrars and consultants) working in EDs across Australia was then undertaken. The survey consisted of 130 items and required approximately 20 min for completion. The survey was delivered online through email invitation by the College of Emergency Nurses Australasia or the Australasian College for Emergency Medicine. A hardcopy format of the survey was also delivered at a national conference. Results: Mental health presentations that involved a diagnosis of personality disorder, psychosis or behavioural disturbance, and the management of these conditions were patient factors that were considered problematic by up to 46.3% (118/255; 95% CI 40.26–52.40) of doctors and 66.1% (72/109; 95% CI 56.74–74.28) of nurses. Determining care plans, conducting mental status examinations, assessing risk of self‐harm, pharmacology for treatment and for chemical restraint, management of patient aggression or violence, and alcohol or drug intoxication were also found to be areas of knowledge deficit. Conclusion: Doctors and nurses reported deficits in confidence and knowledge in tasks and patient presentations that they might frequently be expected to manage. These data can be used to inform future curricula at both undergraduate and postgraduate levels. Ultimately, this might pave the way for improved care and management of patients with mental health problems presenting to the ED.     

Evaluation of an electroconvulsive therapy service in a general hospital

There has been much recent literature on the technical parameters of electroconvulsive therapy (ECT) with regard to improving efficacy and minimizing adverse effects, but relatively little on ECT service delivery. This paper will discuss the development and characteristics of an ECT service at a teaching hospital in metropolitan Sydney, New South Wales, Australia. A mixture of qualitative and quantitative methods, including a selective literature review and audit of ECT use were used. The results of the audit were compared with the 2007 revision of the Royal Australian and New Zealand College of Psychiatrists' clinical memorandum on ECT. We discuss issues, such as the optimal site for ECT delivery, ECT mental health nurse coordinator role, credentialing of psychiatrists, registrar supervision, and the development of an ECT committee. A significant finding of the audit was that the majority of patients were treated under the New South Wales Mental Health Act, and voluntary patients were more likely to have a diagnosis of a depressive disorder, whereas involuntary patients were more likely to have a non-mood disorder diagnosis. This study has shown that auditing of ECT practices and services by mental health nurses is essential for quality improvement processes. The audit highlighted areas of service delivery that should be subject to review and evaluation against professional standards.     

Violence: part of the job for Australian nurses?

According to a recent Australian Institute of Criminology report (1999) the health industry is the most violent industry in Australia. In this paper the authors aim to highlight violence as an important professional issue for Australian nurses that is currently concealed as 'part of the job'. National and international studies bring attention to the severity of the problem for nurses with a particular focus on emergency nurses. Some of the issues identified and discussed include increased waiting times and frustration; increasing use of weapons; inadequate systems of security; culture of silence; inadequate support for emergent mental health needs; lack of reporting; lack of institutional concern and systems of support, and; demands of triage nursing. The nature of workplace violence in emergency departments in New South Wales and South Australia will be explored based on the authors' research. A research pathway to explore national impact and implications of violence for nurses and nursing practice in general will be outlined.     

Making us what we are: Noteworthy people and achievements in Queensland mental health nursing

Understanding mental health nursing's past is an important way to preserve our cultural heritage. By exploring and then disseminating the insights gained through examination of the past, students and practicing mental health nurses may become more aware of the social and intellectual origins of the profession. They may also have their professional connections and commitment to mental health nursing clarified and reconfirmed. This paper presents the results of a survey conducted in Queensland in 2009. Members of the Australian College of Mental Health Nurses were invited to identify mental health nurses who they perceived had made a noteworthy contribution to the profession. Twenty mental health nurses were identified from the 38 surveys received. The reasons underlying the nominations revealed two main themes: achievements and qualities. Achievements included the subthemes: practice pioneer; career longevity; and far reach of influence. Qualities included: inspirational role model; and passion, dedication and/or commitment. The study provides a beginning conversation on the preservation of heritage and recommends deeper exploration of the history of mental health nursing within Australia, and specifically Queensland.     

A continuing educational initiative to develop nurses' mental health knowledge and skills in rural and remote areas

At a time of ever increasing mental health problems in Australian society, the nursing profession is beset by problems of an insufficient workforce specialising in this area. Not only is there a shortage of suitable trained specialist mental health nurses, but undergraduate nursing programs inadequately prepare students for practical mental health nursing. Fewer students are enrolling in mental health nursing, and many nurses are leaving the workforce. A particular problem in rural Australia is that there is a lack of specialist mental health services, and nurses are being increasingly relied upon to perform the role of mental health nurse despite lacking the necessary qualifications and experience.This paper aims to describe the development, implementation and evaluation of a mental health continuing education program for nurses employed in rural and remote areas of New South Wales (NSW), Australia. This was a collaborative educational initiative mounted by the NSW Health Department (who funded the project), a rural university and a number of regional health service partners. The paper includes information on how this program was conceived, developed and conducted through distance education mode. It also evaluates the efficacy of this program as perceived by 202 out of 303 participants. Overall the project was rated very favourably, and represents a cost-effective, convenient method of enabling rural and regional nurses to update and improve their skills in mental health nursing.     

Screening for Symptoms of Postpartum Traumatic Stress in a Sample of Mothers with Preterm Infants

People with serious mental illness are at high-risk for physical illnesses and premature death, and nurses can contribute to ensuring mental health services address these risks. There is very little research examining the role of nurses in mental health who provide physical health care. To identify the levels of participation in physical health care of people with serious mental illness (SMI), a national Internet-based survey of nurses working in mental health in Australia was conducted (n = 643). The survey included an adapted version of the Robson and Haddad Physical Health Attitude Scale. Data were analysed through comparison of frequencies, correlations, principal components analysis, and Mann-Whitney tests. Nurses reported regular physical health care in 12 of the 17 tasks presented to them. The three most common self-reported physical health care activities were inquiring about consumers’ contact with GPs, doing physical assessments, and providing information on drug use and lifestyle. Although some practices were less common (e.g., contraceptive advice) nurses who provided one type of care tended to do other types as well. In addition, credentialing in mental health nursing was associated with slightly more regular engagement in all practice domains except screening and assessments. Nurses in mental health in Australia may be engaged in improving physical health of consumers with SMI more than is assumed.