CARE: a framework for mental health practice

Exploration of the utility of the Nursing Process and the Clinical Reasoning Cycle as a framework for forensic mental health nurses: A qualitative study

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce.

Self-harm presentations in emergency departments: staff attitudes and triage

Addressing the rising incidence of self-harm and the demand this places on emergency departments (EDs) are UK Government healthcare priorities. A history of self-harm is linked with suicide risk, so self-harm is a public health issue. The ED is the first point of contact for many people who self-harm so it plays a pivotal role in access to services. Research has highlighted difficulties around triage and assessment in EDs of patients who self-harm, especially frequent attenders. The evidence base on patient experience related to addressing negative staff attitudes is lacking, despite their potent nature and impact on care. Limited knowledge of self-harm aetiology and clinical inexperience have been found to be fundamental to nurses' negative attitudes when dealing with patients who self-harm. This has been linked to negative patient outcomes, including a reluctance to engage with services. This article acknowledges positive changes that have been made and highlights the importance of the triage stage, which is a potential service improvement area, where it would be possible to start and drive positive change in the care of people who self-harm. To address knowledge gaps in education and management, clinical understanding of the aetiology of self-harm should be improved with the aid of education on self-harm cycles. Nurses should also be made aware of common myths surrounding self-harm, as these are barriers to care. Recommendations for practice include partnership working and the urgent need for formal education on this topic for all health professionals working in EDs.

Fostering resilience later in life: a narrative approach involving people facing disabling circumstances, carers and members of minority groups

Over the last two decades, the concept of resilience has become the focus of a growing body of gerontological research. However, there is a dearth of qualitative research that explores how socio-economic and socio-cultural factors shape older people's resilience. This study addresses this gap and explores the concept of resilience through the lens of 25 Australians from a variety of backgrounds, investigating the resilience strategies they employed in the face of different challenging life events. A qualitative narrative methodology involving one focus group and semi-structured interviews was employed. A stratified convenience sample of 34 people aged 60 and over participated in semi-structured interviews between 2009 and 2011. The study describes the meaning participants assigned to the term resilience, and focuses on the range of resilience responses and strategies they employed, bringing to light some key commonalities and differences. The study's findings suggest that access to economic and cultural resources and the nature of the adversity older people face can shape and limit their resilience strategies. The article outlines how the concept of resilience could be incorporated into aged care practice and argues that resilience-focused interventions that potentially broaden the resilience repertoire of older people should be explored within an aged care context.

Mental health community liaison in aged care: a service of value to all

Aim.  This paper describes an effective community nursing role in which mental health care is brought to long-term care in a way that restores and promotes mental health wellbeing in the older person, builds understanding between clinicians, and develops staff confidence in attending to the whole needs of residents of nursing homes. Background.  Mental health is a significant issue in the ageing population and there is much that mental health nurses as well as staff in long-term care can do to promote early detection of problems, facilitate effective treatment and build coping in the older person and family so that they recover from grief or depression issues and go on to make this stage of life satisfying and rewarding. Conclusions.  The mental health nurse liaison role is a useful contribution to comprehensive aged care in the community. The role provides support to clinicians enabling them to develop skills and expand their area of practice, whilst creating an environment in which the needs of the client may also be better understood and thereby met.

The art of mental health practice: the role of drama in developing empathy

PURPOSE

This paper explores concepts central to acting, and details how these concepts can be related to mental health nursing practice.

DESIGN AND METHODS

The work of the acting theorists Constantin Stanislavski and Lee Strasberg is examined and recontextualized to illustrate how their work is relevant in modern mental health practice, and the development of empathy.

FINDINGS

While these concepts are still utilized in drama, they have not been fully explored in their original context. Their use could combat stress and burnout, heighten awareness, and enhance the projection of emotions.

PRACTICE IMPLICATIONS

These concepts can be linked with reflective practice in mental health, and a stronger emphasis on the values of this approach could allow the nurse to strengthen the level of empathy they demonstrate.

The lived experiences of single Taiwanese mothers being resilient after divorce

The lived experiences of being resilient as described by 13 single Taiwanese mothers after divorce was the focus of this study. A descriptive phenomenological approach to inquiry was the theoretical framework underpinning the study. Information was gathered through two in-depth face-to-face digitally recorded interviews with each participant. Each of the participants had suffered from depression. For the analysis of the participants' transcripts of interview the authors used Colaizzi's method. Four themes emerged from the analysis process: having faith in God, bending with the ebb and flow of daily life, finding strength in the support and friendship of others, and new found freedom and hope for the future. Findings of this study have the potential to enhance understanding of the mental health needs of single mothers and their children in the provision of holistic health care delivery.

Ordinary people, extraordinary voices: The emotional labour of lay people caring for and about people with a mental health problem

Many attempts to reduce the stigmatization of people with mental illness have often been predicated, based on the desire to persuade the public that people with mental illness are 'ill' in the same way as people with medical conditions. This paper presents one aspect from the findings of a study that examined the ways in which lay people perceived mental health and illness. Data are drawn from the discussion of the roles and experiences of different non-mental health professionals who cared for and about people they met in their everyday employment. In this paper, we argue that central to these roles is the importance of listening to people in an arena which is non-statutory and without judgment. We demonstrate that people use popular sectors when they are unsure of the problem they have, or they are reluctant to refer themselves to the professional sector. The paper presents narrative extracts illustrating the emotional labour operating in each participant's role and the extent to which they provide support for their client's emotional and psychological well-being. The implications for mental health nursing are discussed in relation to working with and alongside people experiencing mental distress, in relation to 'ordinary human qualities'.

Blending practice development methods with social science research: an example of pushing new practice research boundaries

Innovating research methods to better suit clinical contexts and practice puzzles is key to the advancement of practice. To illustrate a mechanism by which this development can be achieved the authors offer a research narrative which is revealing of their thinking, methodological positioning and research activities as they sought to innovate a research design to suit the clinical issues, puzzle and research context. The trigger for this innovative research design was the opportunity provided by a short timeframe and small amount of research funding to work with a health board clinical puzzle to explore presentations of older people to emergency departments in relation to those could be avoided, and by implication consider how better ways of caring for older people could be devised. In the example provided, the authors reveal how they blended practice development methods with collaborative action research to develop a reconnaissance study. The findings and outcomes of the study are affirming of the approach, methodological strategy and use of practice development methods to support engagement and puzzling as methods which support reconnaissance in relation to a complex clinical scenario such as ‘avoidable’/‘inappropriate’ presentation of older persons in the emergency department.

Clínica ampliada em saúde mental: cuidar e suposição de saber no acompanhamento terapêutico

Este trabalho investiga o acompanhamento terapêutico, entendido como intervenção em saúde mental baseada em cuidados domiciliares. Destacamos a importância de intervenções comunitárias privilegiando formas de lidar com o sofrimento, seja através de uma concepção médica dos sintomas, fundada na visibilidade, seja valorizando uma leitura psicanalítica que recorre à escuta. Carecendo de teorização independente que fundamente sua prática, o AT (acompanhamento terapêutico) apropria-se de teorias provenientes de outros campos do saber que guardam afinidades. Neste sentido, abordamos a influência da psicanálise e sua participação na clínica ampliada em saúde mental através da prática clínica do AT, utilizando dois conceitos operatórios de amplo alcance, que são: sujeito suposto saber, proveniente da obra de Lacan, e cuidado, derivado de Winnicott. Ambos respondem a questões do campo teórico e orientam a atuação clínica. Concluímos que o AT realiza exigências do manejo transferencial sob a forma do cuidar exercido no cotidiano do sujeito, no qual desejo e subjetividade são necessariamente reconhecidos, sem que se configure como tecnologia psicoterápica, situando-se mais propriamente como sentinela clínica no campo da psiquiatria comunitária e saúde coletiva.

Role of psychological factors in studying recovery from a transactional stress-coping approach: implications for mental health nursing practices

Over the last decade, the experience of recovering from psychiatric disabilities has received increased attention in mental health nursing. Recovery is a complex experience that can be understood in terms of construct, process, and outcomes. New theoretical frameworks are needed to better understand antecedents, process variables, and outcomes related to recovery. Considering that recovery is a stressful and challenging experience, the transactional stress-coping theory appears relevant to explore the appraisal and coping processes involved in recovery. Based on this theory, a new framework has been built to better understand the phenomenon of stress in recovery. More specifically, a review of the recovery literature had led to the identification of several key recovery concepts, which were then linked to major stress-coping concepts, namely contextual factors, potential stressors, primary and secondary appraisals, coping strategies, and short-term and long-term outcomes. This paper focuses on specific types of personal characteristics that are included in the broad category of contextual factors, namely psychological factors. These factors may act as coping resources, helping people to deal successfully with events interfering with the achievement of recovery goals. The main purpose of this paper is to offer a detailed discussion about how mental health nursing practices may promote the role of psychological factors within the stress-coping process. Three categories of psychological factors are discussed: views about oneself, psychological empowerment, and personal/philosophical orientations in life. A brief summary of the new framework is first offered to introduce its major concepts and basic mechanisms.

Promoting reflection in mental health nursing practice: a case illustration using problem-based learning

Reflective practice in nursing has been shown to improve both client care and nurses role satisfaction. Students require regular and guided opportunities to learn the necessary reflective skills that underpin best practice. Problem-based learning (PBL) processes based on comprehensive learning packages developed from actual clinical cases provide a contextualized and realistic means for students to develop and hone their reflective skills for use as mental health practitioners. This paper uses a case illustration to demonstrate the usefulness of PBL as a mechanism for developing reflective practice in the mental health context. Students analysed five cases drawn from actual documented clinical materials that included nursing, medical and allied health professionals' assessments, treatment regimes, and progress notes. One student's written analysis of the five cases and an interview with the student is presented as a case illustration. The case illustrates the student's reflections on the theme of 'hope' for the clients and identified three obstacles. These were: (i) a lack of acknowledgement by health professionals of traumatic life events; (ii) overlooking less tangible losses; and (iii) a central focus on drug treatment. Reflective learning strategies can be incorporated in on- and off-campus learning environments and used to assist the learner to practise critical reflective skills in a controlled and safe manner. Reflective processes are more meaningful if the PBL package that students encounter represents real clinical scenarios with comprehensive resource materials.

The experience and views of mental health nurses regarding nursing care delivery in an integrated, inpatient setting

Positive and effective consumer outcomes hinge on having in place optimal models of nursing care delivery. The aim of this study was to ascertain the experience and views of mental health nurses, working in hospitals in an area mental health service, regarding nursing care delivery in those settings. Surveys (n = 250) were sent to all mental health nurses working in inpatient settings and 118 (47%) were returned. Results showed that the quality of nursing care achieved high ratings (by 87%), and that two-thirds of respondents were proud to be a mental health nurse and would choose to be a mental health nurse again. Similarly, the majority (71%) would recommend mental health nursing to others. Concern was, however, expressed about the continuity and consistency of nursing work and information technology resources. Nurses with community experiences rated the importance of the following items, or their confidence, higher than those without previous community placements: the importance of interdisciplinary teamwork; the importance of participating in case review; the importance of collaborating with community staff; confidence in performing mental state examinations; and confidence in collaborating with community staff, suggesting that this placement had positive effects on acute care nursing.

Countertransference and self-injury: a cognitive behavioural cycle

AIM

This paper discusses the emotional, cognitive and behavioural effects of self-injury on nurses as helpers, and shows the usefulness of a cycle that can affect care provision for this group of people.

BACKGROUND

People self-injure for many different reasons, such as feeling angry, sad, guilty or frightened, and these emotions are often linked to feeling helpless, powerless or out of control. Self-injury has often been reported as a coping strategy to gain control. Psychoanalytic and cognitive behavioural concepts have been used to understand why people self-injure and also inform intervention strategies. Unfortunately, negative emotional responses in professionals may interfere with the effectiveness of any therapeutic relationship.

DISCUSSION

Negative emotional responses from nurses can affect the way they think about and behave towards clients who self-injure. During clinical supervision or education, nurses' thoughts can be challenged to become less negative, so that their resulting behaviour can also become less punitive. Non-punitive or more positive behaviour can in turn challenge some of the negative self-beliefs of clients.

CONCLUSIONS

Knowledge about countertransference when working with people who self-injure may reduce nurses' negative thoughts and behaviours, which may result in improved client care.

Adversity as opportunity: living with schizophrenia and developing a resilient self

Approximately 1% of the population is diagnosed with schizophrenia, and despite longstanding critiques of the (bio)medical model, understanding of the disorder still arises primarily through (bio)medical explanations. In turn, causation, symptoms and treatments are increasingly sophisticated and well known while understanding of other aspects of the disorder, especially the intersubjective experience of people living with schizophrenia, remains fragmented. For this reason, the present study sought to understand how people experience schizophrenia. To do this, the stories of 19 people diagnosed with the disorder were hermeneutically interpreted. These stories appeared in The Schizophrenia Bulletin--a journal which publishes 'first person accounts', sometimes anonymously, of people's experience of mental illness. Within the study context, the findings indicate that facing the adversity of schizophrenia means living: (i) wisely--understanding the nature of self-with-schizophrenia and of life-with-schizophrenia; (ii) mindfully--keeping understandings in conscious thought; and (iii) purposefully--acting deliberately. Doing this results in a stable and meaningful life and in a different, more resilient self.

CARE: A framework for responding therapeutically to the client who self-harms

The CARE framework is a relevant, flexible and practical tool that can be used to map out a plan of care for helping the client who deliberately self-harms. A clear framework for care is useful for clinicians and consumers because ideally it provides a standard, holistic and considered approach for what is a complex health care issue. This paper recounts a story from clinical experience in which the CARE framework was applied. In this encounter, the nurse was helped to move beyond the limitations of the medical model towards an approach which proved satisfying for the health professional, and awakening for the client.