There is more to risk and safety planning than dramatic risks: Mental health nurses’ risk assessment and safety‐management practice

Risk assessment and safety planning are considered a cornerstone of mental health practice, yet limited research exists into how mental health nurses conceptualize ‘risk’ and how they engage with risk assessment and safety planning. The aim of the present study was to explore mental health nurses’ practices and confidence in risk assessment and safety planning. A self‐completed survey was administered to 381 mental health nurses in Ireland. The findings indicate that nurses focus on risk to self and risk to others, with the risk of suicide, self‐harm, substance abuse, and violence being most frequently assessed. Risk from others and ‘iatrogenic’ risk were less frequently considered. Overall, there was limited evidence of recovery‐oriented practice in relation to risk. The results demonstrate a lack of meaningful engagement with respect to collaborative safety planning, the identification and inclusion of protective factors, and the inclusion of positive risk‐taking opportunities. In addition, respondents report a lack of confidence working with positive risk taking and involving family/carers in the risk‐assessment and safety‐planning process. Gaps in knowledge about risk‐assessment and safety‐planning practice, which could be addressed through education, are identified, as are the implications of the findings for practice and research.     

Deconstructing risk assessment and management in mental health nursing

RATIONALE: Risk assessment and management have a taken a central position in the delivery of contemporary mental health services. However, these concepts are generally taken-for-granted as necessary and unavoidable aspects of mental health nursing practice. This deconstructive analysis explores some of the assumptions and values that underpin these concepts. AIMS: The aims of the study were to provide a deconstructive analysis of the concepts of risk and risk management, and to explore the historical context of mental disorder and the concept of risk, the clinical context of risk assessment and management, the cultural, political and economic context of risk, and the impact on mental health nursing and consumers of mental health services. DESIGN: This paper takes a deconstructive approach to the exploration of the historical, clinical, cultural, political and economic context of the concept of risk and its assessment and management. This is undertaken by providing a critical review of the history of mental illness and its relationship to risk, examination of government policy on clinical risk management, analysis of a risk assessment model and a discussion of the political and economic factors that have influenced the use of risk assessment and management in clinical practice. FINDINGS: The concept of risk and its assessment and management have been employed in the delivery of mental health services as a form of contemporary governance. One consequence of this has been the positioning of social concerns over clinical judgement. The process employed to assess and manage risk could be regarded as a process of codification, commodification and aggregation. In the mental health care setting this can mean attempting to control the actions and behaviours of consumers and clinicians to best meet the fiscal needs of the organization. CONCLUSION: The mental health nursing profession needs to examine carefully its socially mandated role as guardians of those who pose a risk to others to ensure that its practice represents its espoused therapeutic responsibilities.     

Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: Associations and impact on aggressive behaviour

Aim and objectives

To examine associations between risk of aggression and nursing interventions designed to prevent aggression.

Background

There is scarce empirical research exploring the nature and effectiveness of interventions designed to prevent inpatient aggression. Some strategies may be effective when patients are escalating, whereas others may be effective when aggression is imminent. Research examining level of risk for aggression and selection and effectiveness of interventions and impact on aggression is necessary.

Design

Archival case file.

Methods

Data from clinical files of 30 male and 30 female patients across three forensic acute units for the first 60 days of hospitalisation were collected. Risk for imminent aggression as measured by the Dynamic Appraisal of Situational Aggression, documented nursing interventions following each assessment, and acts of aggression within the 24‐hours following assessment were collected. Generalised estimating equations were used to investigate whether intervention strategies were associated with reduction in aggression.

Results

When a Dynamic Appraisal of Situational Aggression assessment was completed, nurses intervened more frequently compared to days when no Dynamic Appraisal of Situational Aggression assessment was completed. Higher Dynamic Appraisal of Situational Aggression assessments were associated with a greater number of interventions. The percentage of interventions selected for males differed from females; males received more pro re nata medication and observation, and females received more limit setting, one‐to‐one nursing and reassurance. Pro re nata medication was the most commonly documented intervention (35.9%) in this study. Pro re nata medication, limit setting and reassurance were associated with an increased likelihood of aggression in some risk bands.

Conclusions

Structured risk assessment prompts intervention, and higher risk ratings result in more interventions. Patient gender influences the type of interventions. Some interventions are associated with increased aggression, although this depends upon gender and risk level.

Relevance to clinical practice

When structured risk assessments are used, there is greater likelihood of intervention. Intervention should occur early using least restrictive interventions.

     

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.     

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.     

Prevalence of burnout in mental health nurses and related factors: a systematic review and meta‐analysis

The aim of this study was to determine the prevalence of burnout in mental health nurses and to identify its predictors. A systematic review was conducted of studies published in the following databases: CINAHL, Dialnet, LILACS, ProQuest, PsycINFO, PubMed, SciELO, and Scopus. The search equation used was “Nurs * AND Burnout AND mental health”. Subsequently, three fixed‐effects meta‐analyses were performed, one for each dimension of burnout, to calculate its prevalence and the corresponding confidence intervals. The data were analysed using StatsDirect meta‐analysis software. Eleven studies were finally included (n = 11). In most cases, the literature informs about moderate levels of emotional exhaustion, depersonalization, and personal accomplishment. The studies inform that variables such as work overload, work‐related stress, professional seniority, male gender, being single, and aggression at work, among other factors, contribute to burnout development. The meta‐analytic prevalence estimations of burnout with a sample of n = 868 mental health nurses are 25% for high emotional exhaustion, 15% for depersonalization, and 22% for low personal accomplishment. From a workforce development and safety perspective, it is important for managers to address the emotional exhaustion and low personal accomplishment aspects of burnout reported in the workplace by mental health nurses.     

Examining the relationship between risk assessment and risk management in mental health

Thorough risk assessment helps in developing risk management plans that minimize risks that can impede mental health patients' recovery. Department of Health policy states that risk assessments and risk management plans should be inextricably linked. This paper examines their content and linkage within one Trust. Four inpatient wards for working age adults (18-65 years) in a large mental health Trust in England were included in the study. Completed risk assessment forms, for all patients in each inpatient ward were examined (n= 43), followed by an examination of notes for the same patients. Semi-structured interviews took place with ward nurses (n= 17). Findings show much variability in the amount and detail of risk information collected by nurses, which may be distributed in several places. Gaps in the risk assessment and risk management process are evident, and a disassociation between risk information and risk management plans is often present. Risk information should have a single location so that it can be easily found and updated. Overall, a more integrated approach to risk assessment and management is required, to help patients receive timely and appropriate interventions that can reduce risks such as suicide or harm to others.     

Refocusing acute psychiatry, performance management, standards and accountability, a new context for mental health nursing

The term 'performance management' has an aversive 'managerial' aspect, is unappealing to many public sector staff and has an 'image problem'. Perhaps as a consequence, it has failed to make a significant impact on Irish public sector workers, notably mental health nurses. In this paper, performance management is introduced and examined within an Irish healthcare context and with reference to its use in other countries. Some of the challenges faced by Irish mental health nurses and the potential benefits of working within a performance managed workplace are discussed. The paper concludes that performance management is likely to increasingly affect nurses, either as active agents or as passive recipients of a change that is thrust on them. The authors anticipate that the performance management 'image problem' will give way to recognition that this is a fundamental change which has the potential to enable health services to change. This change will bring high standards of transparency, worker involvement in decision making, an explicit value base for health services and individual teams. It provides the potential for clear practice standards and high standards of transparency as well as worker welfare in all aspects, including supporting employment and career progression.     

An evaluation of a combined education and multi-project practice development programme in mental health

This paper describes a unique mental health practice development programme, which aims to integrate education, research, clinical practice and culture change, and promote collaboration between academics, researchers and healthcare practitioners to meet current government policy needs. The programme combines academic qualifications within the context of practice development and aims to produce practitioners who are dynamic leaders, capable of critical thinking, influencing culture change and challenging the nature of conventional practice. The aim of the evaluation was to give insight into participants' experience of the programme using a qualitative approach. Open-ended questionnaires obtained participant's views on facilitation and module content. Focus groups discovered the views and experiences of participants of the programme. The findings showed that the programme was well-received and impacted positively on both patient care and the personal and professional development of participants. The findings were used to modify the programme for the next intake of participants. The research complements the existing body of knowledge on practice development and highlights the benefits for staff, nurses and service users, and the challenges of implementation. The framework and design has the potential to be applied to other areas of practice beyond mental health.     

Towards a Foucauldian reading of the Australian mental health nursing workforce

This article reflects on the findings of the recently published Scoping Study of the Australian Mental Health Nursing Workforce from the perspective of Foucault's work on 'governmentality'. First, the policy background to the scoping study is described. This is followed by a discussion of Foucauldian concepts and method that will be used to explore selected aspects of the scoping study. The related concepts of 'governmentality' and 'technologies of the self' are used to begin a theoretically grounded analysis of mental health nursing education and practice, with particular attention to discourses of 'change' and 'survival'. The examples chosen are used to support the argument that competing discourses order multiple 'readings' of Australian mental health nursing, including whether or not it is thriving or surviving. The article ends with comments on whether a Foucauldian analysis adds anything to what has been reported in the scoping study.     

Risk assessment and management of patients with self-neglect: a 'grey area' for mental health workers

This study explores the perceptions and experiences of community mental health workers who assess and manage the risk of self-neglect and severe self-neglect in people with serious mental health problems. The initial literature review demonstrated a lack of material on this specific subject. Semi-structured interviews were undertaken with seven community mental health workers who met the criteria of being knowledgeable, skilled and credible practitioners. Data analysis was completed using thematic content analysis. Findings suggest that community mental health workers are operating in a number of areas where there is a distinct lack of clarity--'The Grey Areas'. The most important of these were the tolerance of workers to situations of self-neglect/severe self-neglect, policies, procedures and legislation, and definitions of self-neglect/severe self-neglect. The workers dealt with this lack of clarity by completing a detailed risk assessment, which then enabled them to manage the risk. However, the need to balance the safety needs of clients against their need to be treated as autonomous individuals presented a major dilemma for workers.     

Risk assessment and management: a community forensic mental health practice model

In Victoria, the Crimes (Mental Impairment and Unfitness to be Tried) Act (1997) reformed legal practice in relation to the detention, management and release of persons found by a court to be not guilty on the grounds of insanity or unfit to be tried. This Act provides a legal structure for such 'forensic patients' to move from secure inpatient facilities into the community. This new legislative landscape has generated challenges for all stakeholders and has provided the impetus for the development of a risk assessment and management model. The key components of the model are the risk profile, assessment and management plan. The discussion comprises theory, legislation, practice implications and limitations of the model. Practice implications concern the provision of objective tools, which identify risk and document strategic interventions to support clinical management. Some of the practice limitations include the model's applicability to risk assessment and management and its dependence on a mercurial multi-service interface in after-hours crisis situations. In addition to this, the paper articulates human limitations implicit in the therapeutic relationship that necessarily underpins the model. The paper concludes with an exploration of the importance of evaluative processes as well as the need for formal support and education for clinicians.     

Making a spectacle of herself: Reading community mental health nursing assessments

The metaphor of mapping is used in this paper to examine the discursive construction of women whose nudity in public places (making a spectacle of herself) provides dilemmas for community mental health nurses required to make assessments of these women's ability to function in die community. Excerpts from stories provided by die nurses are used to demonstrate the complexity of die decision-making processes and the limits to die choices they perceive they can make.     

Nursing interventions for adults following a mental health crisis: A systematic review guided by trauma‐informed principles

There exists a growing need for health and service providers to respond to persons in a manner that recognizes the prevalence and impact of trauma in individuals and prevent inadvertent re‐traumatization in the routine process of care. The experience of mental health crisis in of itself can have traumatic and impactful effects on individuals. Trauma‐informed approaches to care offer a framework to provide crisis intervention responses that are based on the acknowledgement of the prevalence and impact of trauma and define trauma not by the event per se, but by the impact of an experience of trauma. The integration of trauma‐informed principles in the context of crisis intervention is a current practice gap. In order to inform a portion of a best‐practice guideline for registered nurses and the interprofessional team, a systematic literature review was conducted to primarily identify nursing interventions within four weeks of a mental health crisis, with a secondary focus on identifying particular interventions that included trauma‐informed principles. The systematic review yielded 21 quantitative and qualitative studies related to nursing interventions for mental health crisis, 10 of which referred to one or more principles of trauma‐informed approaches. There was a lack of studies on nursing interventions explicitly linked to implementation of trauma‐informed principles, highlighting future research needs and focused efforts to integrate trauma‐informed principles into crisis intervention practices.     

Community mental health nurses, caseloads, and practices: a literature review

Deinstitutionalization, and more recently, earlier discharges from psychiatric inpatient units, have created and intensified the need for case management in community mental health. Nurses have been at the forefront of providing this case management. This literature review provides a synthesis of research and policy on the contribution of mental health nurses to community case management. The focus of this review is on the proportion of case management that mental health nurses undertake, the caseloads of case managers, and the interventions that mental health nurses most frequently perform in the community. The professional compositions of mental health case management workforces have been associated with economic imperatives, professional priorities, and the choice of case management models. The influence of mental health nurses in the case management workforce is particularly strong in the U.K. and Australia, but less so in the U.S.A. where social workers and people without mental health qualifications perform similar roles. Although heavy caseloads seem to be common among case managers, the research in this area is quite weak. The interventions that mental health nurses perform most often include case management (e.g., coordinating care), counselling, and medication management. Caring for the physical health of consumers might often be overlooked.     

A lack of therapeutic engagement and consumer input in acute inpatient care planning limits fully accountable mental health nursing practice

It is mental health consumer's human right to lead a fulfilling life as they are empowered to actively manage their recovery. This can be facilitated through care planning, yet research suggests that the care plan is not routinely created, discussed, or updated in acute mental health settings. Research on care planning and the role of the mental health nurse highlights the importance of therapeutic communication in care plan development. This paper argues that the lack of meaningful care plan discussions between consumers and mental health nurses in an acute setting is a limitation to the practice of fully accountable mental health nursing care. We explore this limitation in quality care provision by examining literature on accountability and conclude that in mental health nursing, accountability is frequently enacted through an overarching focus on the organizational need to manage risks, rather than on therapeutic engagement.     

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.     

空巢老人心理健康评估工具研究进展

空巢老人在生命周期及家庭周期转型过程中的心理健康问题日渐凸显,心理健康的评估是心理健康维护与促进的基础性工作。对空巢老人心理健康的评估工具进行了综述,以期为准确评价空巢老人心理健康问题,制定科学的心理干预策略提供理论依据。