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

Mental Health Risk Assessments of Patients, by Nurses Working in Mental Health Settings: A Qualitative Study Using Cognitive Continuum Theory

Mental health risk-assessments are an important part of nursing in mental health settings, to protect patients or others from harm. Even so, nurses often have difficulty identifying patients posing a credible risk (either to self or others), so guidance is recommended. However, despite an extensive and growing body of risk-oriented literature, comparatively little expands upon contemporary knowledge of nurses and patient risk assessment. Therefore, it remains unclear how nurses understand risk and undertake their risk assessments. To address this knowledge gap in nurses' decision-making processes, this study used the established Cognitive Continuum Theory as a novel means to explore the risk-assessment of patients by nurses working in mental health settings.

Approaches and challenges to assessing risk of violence in first episode psychosis: A qualitative interview study of clinicians, patients and carers

AIM

Clinical services for early psychosis seek to improve prognosis for a range of adverse outcomes. For some individuals, perpetration of violence is an important potential outcome to reduce. How these clinical services currently assess this risk however is uncertain. This study aimed to address this gap by using qualitative methods to examine in depth current approaches, attitudes and challenges to assessing violence risk in this clinical setting, from the perspectives of multidisciplinary clinicians, patients and carers.

METHODS

Participants were recruited from two UK Early Intervention in Psychosis services. Semi-structured individual interviews were undertaken using a topic guide. In addition, clinical vignettes were presented to clinician participants as a probe to prompt discussion. Data were analysed using thematic analysis, informed by the constant comparative method.

RESULTS

We conducted 30 qualitative interviews, of 18 clinicians and 12 patients and carers. Themes developed from clinician interviews included key difficulties of low confidence, limited training, accessing collateral information and variation in how risk is appraised and communicated. Potential stigma and sensitivity of the topic of violence were perceived as barriers to its discussion. Patient and carer perspectives provided insight into how to address barriers, and highlighted the importance of an open approach, including with families.

CONCLUSIONS

We recommend developing contextually appropriate pathways to collaboratively assess violence risk and identify modifiable needs to reduce this risk, and for practical improvements in training and information-sharing.

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Mental health nurses' attitudes towards risk assessment: An integrative systematic review

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and risk management are considered to be important practices carried out by mental health nurses. Risk assessment can help keep mental health service users' safe, but some nurses see it as a 'tick the box' exercise. Some studies have looked at nurses' attitudes to risk assessment but no one has systematically described all the studies. WHAT THE ARTICLE ADDS TO EXISTING KNOWLEDGE?: Mental health nurses' attitudes towards risk assessment are diverse with regard to its legitimacy, conduct and value. This study provides an organised framework to help understand the areas in which these different attitudes occur. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Since attitudes can influence clinical practice, nurses need to reflect on how they view risk assessment. Further research is required to investigate whether particular attitudes are positive or negative and whether attitudes can be changed.

ABSTRACT

INTRODUCTION: Understanding nurses' attitudes towards risk assessment could inform education and practice improvements.

AIM/QUESTION

To explore mental health nurses' attitudes towards risk assessment.

METHOD

An integrative systematic review (PROSPERO: CRD42023398287). Multiple databases (PubMed, CINAHL, MEDLINE, EMBASE and PsycINFO) were searched for primary studies of mental health nurses' attitudes towards risk assessment. Qualitative studies were subject to inductive coding and thematic analysis; quantitative data were integrated with emerging themes.

RESULTS

Eighteen articles were included. Qualitative studies commonly lacked rigorous analyses. Four themes emerged: underlying purpose and legitimacy of risk assessment (philosophical orientation); use of structured approaches (technical orientation); value of intuition (intuitive orientation); and service user involvement (relationships orientation). There were contradictory study findings in each thematic category indicating different attitudes among mental health nurses.

DISCUSSION

Mental health nurses' attitudes towards risk assessment vary in four key domains. Survey studies suggest they are more approving of structured approaches to risk assessment than many qualitative studies suggest. There is a need to develop a valid measure of attitudes to risk assessment.

IMPLICATIONS FOR PRACTICE

This review could help health organisations to develop strategies to improve their risk assessment policies and practice. There is a need to develop structured training and education programmes.

Suicide prevention: What does the evidence show for the effectiveness of safety planning for children and young people? - A systematic scoping review

WHAT IS KNOWN ON THE SUBJECT?: Suicide prevention is an international healthcare priority. There is an urgent need to use approaches that are helpful and follow research evidence. Safety planning is now widely used in suicide prevention; however, it was developed for use with adults, and little is known about its effectiveness for children/young people. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic scoping review brings together all research evidence since 2008 that reported how effective safety planning is for children/young people. Findings highlight that when healthcare professionals help children/young people who are suicidal, they need to ensure that the safety plan is completed collaboratively with healthcare professionals and children/young people and that it is appropriate for their age and development. There is also need for healthcare professionals to better recognize and respond to the needs of parents/carers who are caring for a child/young person with suicidal ideations/behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is some research indicating that safety planning is effective for use with children/young people, but such evidence has primarily been obtained from females and there is need for more evidence from male study populations. Further research on its use is needed for certain groups of children/young people including those who are care experienced, or identify as lesbian, gay, bisexual and transgender. This review highlighted that healthcare professionals need specific training before they deliver safety planning for children/young people. It was identified that parents/carers have additional needs and should be involved in safety planning. An additional resource specifically for parents/carers should be developed.

ABSTRACT

INTRODUCTION: Suicide is a leading cause of death for children and young people and its prevention is a global priority. Many Mental Health Services employ safety planning as a brief intervention. There is some evidence of safety planning effectiveness for adults, but little is known about its effectiveness with young people.

AIM

To synthesize research reporting safety planning effectiveness for children/young people with suicidal ideation and identify good practice recommendations.

INCLUSION CRITERIA

The review relates to safety planning around suicide prevention for children/young people aged less than 18 years, even if it was within a wider intervention. The review was inclusive of all clinical areas (including mental health, primary care, etc), any geographical location or social economic status and inclusivity around the method of delivery.

METHODS

A systematic scoping review of literature reporting effectiveness data for the use of safety planning with children/young people with suicidal ideation. The systematic scoping review protocol (pre-registered with Open Science Framework) followed Joanna Briggs Institute conduct guidance and PRISMA-ScR checklist.

DATA ANALYSIS AND PRESENTATION

Fifteen studies were reported during 2008-2021. Overall, there is promising, but limited, evidence of effectiveness for safety planning for children/young people but with complete evidence gaps for some demographic sub-groups. Evidence determined that healthcare professionals should deliver a safety planning intervention that is completed collaboratively, developmentally appropriate, and recognizes parental/carer involvement.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

Further research is needed but current evidence suggests safety planning should be a routine part of care packages for children/young people with suicidal ideation proportionate to their needs. Developing/implementing these plans needs bespoke health professional training and additional support and resources for parents/carers should be developed.

Staff experiences of a novel in-reach rehabilitation and recovery service for people with profound and enduring mental health needs

This organizational case study addresses the research question: What are the experiences of staff who work in a novel in-reach rehabilitation and recovery service for people with profound and enduring mental health needs? Fifteen purposefully sampled staff were recruited from across a novel mental health service that embeds the community sector within inpatient provision. The sample comprises twelve National Health Service and three community voluntary organization staff (four men and eleven women). Data were generated via photo-elicitation in which interviews focused on the photographs participants brought to help convey their experiences of the Service. Interpretative phenomenological analysis was used to analyse the transcripts. The analysis demonstrates that participants are oriented towards five 'meta-questions': What is recovery? Who is valued and how is it demonstrated? Why are you frustrated in doing the best job you can and what support do you need? How can change occur in staff practices and approaches in an environment embedded in history? and How do we make the Service work in the context of constraints? Eight paired themes were also identified regarding staff experience of the Service: hope and individuality; culture and power; communication and confidence; accountability and limitations. The conclusions of this organizational case study have wide relevance to clinical practice: staff (i) place importance on promoting and developing greater awareness of different approaches to care; (ii) aspire to develop better communication across multidisciplinary teams and (iii) desire greater awareness of the complexities of risk to improve staff confidence.

Recovery-oriented mental health principles in psychiatric hospitals: How service users, family members and staff perceive the realization of practices

AIMS

The aim of the study was to describe and compare how recovery-oriented mental health principles have been realized in Finnish psychiatric hospitals from the viewpoint of different stakeholders (service users, family members and staff).

DESIGN

A multimethod research design was adopted to combine both quantitative and qualitative descriptive methods.

METHODS

A total of 24 focus group interviews were conducted with service users (n = 33), family members (n = 3) and staff (n = 53) on 12 psychiatric Finnish hospital wards (October 2017). The interview topics were based on six recovery-oriented principles (WHO QualityRights Tool Kit, 2012). A quantitative deductive analysis was conducted to describe and compare the realization of the recovery-oriented principles between three stakeholder groups. A qualitative deductive content analysis was used to describe participants' perceptions of the realization of recovery-oriented principles in practice. The GRAMMS guideline was used in reporting.

RESULTS

Out of six recovery-oriented principles, 'Dignity and respect' was found to have been realized to the greatest extent on the psychiatric wards. The most discrepancy between the participant groups was seen in the 'Evaluation of recovery'. Service users and family members found the realization of the practices of all principles to be poorer than the staff members did. Wide variation was also found at the ward level between perceptions among participants, and descriptions of the realization of the principles in psychiatric hospital practice.

CONCLUSION

Perceptions about the realization of recovery-oriented principles in practice in Finnish psychiatric hospitals vary between different stakeholder groups. This variation is linked to differing ward environments.

IMPACT

More research is needed to understand the factors associated with variation in perceptions of recovery principles.

PATIENT OR PUBLIC CONTRIBUTION

Service users and family members participated in this study.

Introducing a Digital Occupational Violence Risk Assessment Tool Into an Emergency Department: A Pilot Implementation Study

INTRODUCTION

Occupational violence in emergency departments is prevalent and detrimental to staff and health services. There is an urgent call for solutions; accordingly, this study describes the implementation and early impacts of the digital Queensland Occupational Violence Patient Risk Assessment Tool (kwov-pro).

METHODS

Since December 7, 2021, emergency nurses have been using the Queensland Occupational Violence Patient Risk Assessment Tool to assess 3 occupational violence risk factors in patients: aggression history, behaviors, and clinical presentation. Violence risk then is categorized as low (0 risk factors), moderate (1 risk factor), or high (2-3 risk factors). An important feature of this digital innovation is the alert and flagging system for high-risk patients. Underpinned by the Implementation Strategies for Evidence-Based Practice Guide, from November 2021 to March 2022 we progressively mobilized a range of strategies, including e-learning, implementation drivers, and regular communications. Early impacts measured were the percentage of nurses who completed their e-learning, the proportion of patients assessed using the Queensland Occupational Violence Patient Risk Assessment Tool, and the number of reported violent incidents in the emergency department.

RESULTS

Overall, 149 of 195 (76%) of emergency nurses completed their e-learning. Further, adherence to Queensland Occupational Violence Patient Risk Assessment Tool was good, with 65% of patients assessed for risk of violence at least once. Since implementing the Queensland Occupational Violence Patient Risk Assessment Tool, there has been a progressive decrease in violent incidents reported in the emergency department.

DISCUSSION

Using a combination of strategies, the Queensland Occupational Violence Patient Risk Assessment Tool was successfully implemented in the emergency department with the indication that it could reduce the number of incidents of occupational violence. The work herein provides a foundation for future translation and robust evaluation of the Queensland Occupational Violence Patient Risk Assessment Tool in emergency departments.

Using a Safety Planning Mobile App to Address Suicidality in Young People Attending Community Mental Health Services in Ireland: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Over 700,000 people die by suicide annually, making it the fourth leading cause of death among those aged 15-29 years globally. Safety planning is recommended best practice when individuals at risk of suicide present to health services. A safety plan, developed in collaboration with a health care practitioner, details the steps to be taken in an emotional crisis. SafePlan, a safety planning mobile app, was designed to support young people experiencing suicidal thoughts and behaviors and to record their plan in a way that is accessible immediately and in situ.

OBJECTIVE

The aim of this study is to assess the feasibility and acceptability of the SafePlan mobile app for patients experiencing suicidal thoughts and behaviors and their clinicians within Irish community mental health services, examine the feasibility of study procedures for both patients and clinicians, and determine if the SafePlan condition yields superior outcomes when compared with the control condition.

METHODS

A total of 80 participants aged 16-35 years accessing Irish mental health services will be randomized (1:1) to receive the SafePlan app plus treatment as usual or treatment as usual plus a paper-based safety plan. The feasibility and acceptability of the SafePlan app and study procedures will be evaluated using both qualitative and quantitative methodologies. The primary outcomes are feasibility outcomes and include the acceptability of the app to participants and clinicians, the feasibility of delivery in this setting, recruitment, retention, and app use. The feasibility and acceptability of the following measures in a full randomized controlled trial will also be assessed: the Beck Scale for Suicide Ideation, Columbia Suicide Severity Rating Scale, Coping Self-Efficacy Scale, Interpersonal Needs Questionnaire, and Client Service Receipt Inventory. A repeated measures design with outcome data collected at baseline, post intervention (8 weeks), and at 6-month follow-up will be used to compare changes in suicidal ideation for the intervention condition relative to the waitlist control condition. A cost-outcome description will also be undertaken. Thematic analyses will be used to analyze the qualitative data gathered through semistructured interviews with patients and clinicians.

RESULTS

As of January 2023, funding and ethics approval have been acquired, and clinician champions across mental health service sites have been established. Data collection is expected to commence by April 2023. The submission of completed manuscript is expected by April 2025.

CONCLUSIONS

The framework for Decision-making after Pilot and feasibility Trials will inform the decision to progress to a full trial. The results will inform patients, researchers, clinicians, and health services of the feasibility and acceptability of the SafePlan app in community mental health services. The findings will have implications for further research and policy regarding the broader integration of safety planning apps.

TRIAL REGISTRATION

OSF Registries osf.io/3y54m; https://osf.io/3y54m.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44205.

Perspective: Coping with Covid-19: An isolation risk assessment and management guideline for healthcare staff

The mental health consequences of pandemic isolation have been well documented extending from psychological conditions such as anxiety and depression to increased falls risk, medication errors and delirium. Whilst risk factors associated with isolation are known, there remains a gap in the guidance for healthcare staff on how to assess for these risks and develop effective management plans. Using a structured professional judgement (SPJ) approach and the author's recent experience providing consultation and leadership to clinical staff working with at-risk patients during the pandemic, an isolation risk assessment and management guideline was developed. SPJ is an evidenced-based analytical method used to understand and mitigate risk that was primarily developed for the assessment and management of aggression and violence. This paper discusses an evidenced-based process used to develop the guideline and the application of its use from the author's clinical experience.

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services

INTRODUCTION

Patient safety problems stemming from healthcare delivery constitute a global public health concern and represent a pervasive barrier to improving care quality and clinical outcomes. However, evidence generation into safety in mental health care, particularly regarding community-based mental health services, has long fallen behind that of physical health care, forming the focus of fewer research publications and developed largely in isolation from the wider improvement science discipline. We aimed to investigate the state of the field, along with key conceptual and empirical challenges to understanding patient safety in community-based mental health care.

METHODS

A narrative review surveyed the literature to appraise the conceptual obstacles to advancing the science of patient safety in community-based mental health services. Sources were identified through a combination of a systematic search strategy and targeted searches of theoretical and empirical evidence from the fields of mental health care, patient safety and improvement science.

RESULTS

Amongst available evidence, challenges in defining safety in the context of community mental health care, evaluating safety in long-term care journeys and establishing what constitutes a 'preventable' safety problem, were identified. A dominant risk management approach to safety in mental health care, positioning service users as the origin of risk, has seemingly prevented a focus on proactive safety promotion, considering iatrogenic harm and latent system hazards.

CONCLUSION

We propose a wider conceptualization of safety and discuss the next steps for the integration and mobilization of disparate sources of 'safety intelligence', to advance how safety is conceived and addressed within community mental health care.

PATIENT AND PUBLIC CONTRIBUTION

This paper was part of a larger research project aimed at understanding and improving patient safety in community-based mental health care. Although service users, carers and healthcare professionals were not involved as part of this narrative review, the views of these stakeholder groups were central to shaping the wider research project. For a qualitative interview and focus group study conducted alongside this review, interview topic guides were informed by this narrative analysis, designed jointly and piloted with a consultation group of service users and carers with experience of community-based mental health services for working-age adults, who advised on key questioning priorities.

Cognitive Continuum Theory: Can it contribute to the examination of confidentiality and risk-actuated disclosure decisions of nurses practising in mental health?

Nurses practising in mental health are faced with challenging decisions concerning confidentiality if a patient is deemed a potential risk to self or others, because releasing pertinent information pertaining to the patient may be necessary to circumvent harm. However, decisions to withhold or disclose confidential information that are inappropriately made may lead to adverse outcomes for stakeholders, including nurses and their patients. Nonetheless, there is a dearth of contemporary research literature to advise nurses in these circumstances. Cognitive Continuum Theory presents a single-system intuitive-analytical approach to examining and understanding nurse cognition, analogous to the recommended single-system approach to decision-making in mental health known as structured clinical judgement. Both approaches incorporate cognitive poles of wholly intuition and analysis and a dynamic continuum characterised by a 'common sense' blending of intuitive and analytical cognition, whereby cues presented to a decision-maker for judgement tasks are weighed and assessed for relevance. Furthermore, Cognitive Continuum Theory promotes the importance of determining pattern recognition and functional relations strategies, which can be used to understand the operationalisation of nurse cognition.

Risk for intellectual disability populations in inpatient forensic settings in the United Kingdom: A literature review

BACKGROUND

People with an intellectual disability who commit a criminal offence can be detained, by a court, in a forensic inpatient facility. There is limited understanding of how inpatients with an intellectual disability and their nurses navigate risk in U.K. forensic services.

METHODS

A traditional literature review design was followed to map evidence (2000-2021) around the forensic and health and wellbeing risks faced by inpatients with an intellectual disability, nurses' perceptions of managing risk, and patient experiences of informing risk assessment and management. Papers were analysed thematically.

RESULTS

Findings suggest that restrictive measures to mitigate forensic risks (e.g., violence) can exacerbate the risk of poor health and wellbeing outcomes. There was some limited evidence of direct patient involvement in risk assessment and management.

CONCLUSION

Further research is required to explore how forensic inpatients with an intellectual disability can have input in care planning, risk assessment and management.

The Effects of a Psychodrama-Based Risk Management Training Program on the Knowledge and Practices of Turkish Nurses in Psychiatric Clinics

This study aimed to assess the effects of a psychodrama-based risk management training program on nurses' knowledge and practices. This study used a mixed methods design; quantitative and qualitative methods were used together with a single group pretest, post-test, and follow-up. The training program, in which the nurses took part, comprised six lessons that were designed using psychodrama methods. The result showed that risk management scores increased significantly after the training. Thus, this training is effective for improving the knowledge and practices of mental health nurses for risk management.

Mental health professionals' perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review

BACKGROUND

Risk assessment and risk management are fundamental processes in the delivery of safe and effective mental health care, yet studies have shown that service users are often not directly involved or are unaware that an assessment has taken place. Shared decision-making in mental health systems is supported by research and advocated in policy. This systematic review (PROSPERO: CRD42016050457) aimed to explore the perceived barriers and enablers to implementing shared decision-making in risk assessment and risk management from mental health professionals' perspectives.

METHODS

PRISMA guidelines were followed in the conduct and reporting of this review. Medline, CINAHL, EMBASE, PsycINFO, AMED and Internurse were systematically searched from inception to December 2019. Data were mapped directly into the Theoretical Domains Framework (TDF), a psychological framework that includes 14 domains relevant to behaviour change. Thematic synthesis was used to identify potential barriers and enablers within each domain. Data were then matched to the three components of the COM-B model: Capability, Opportunity, and Motivation.

RESULTS

Twenty studies met the eligibility criteria. The findings of this review indicate that shared decision-making is not a concept commonly used in mental health services when exploring processes of risk assessment and risk management. The key barriers identified were 'power and best interest' (social influences) and 'my professional role and responsibility' (social/professional role and identity). Key enablers were 'therapeutic relationship' (social influences) and 'value collaboration' (reinforcement). The salient barriers, enablers and linked TDF domains matched COM-B components 'opportunity' and 'motivation'.

CONCLUSION

The review highlights the need for further empirical research to better understand current practice and mental health professionals' experiences and attitudes towards shared decision-making in risk assessment and risk management.

Mental health service users experiences of medication discontinuation: a systematic review of qualitative studies

BACKGROUND

The use of psychotropic medication is often the first line of treatment for people with mental distress. However, many service users discontinue their prescribed medication, and little is known about their experiences or the reasons why they choose to stop taking medication.

AIM

The aim of this review is to synthesize research literature focused on the experiences of people who decided to discontinue taking medication for their mental health problem.

METHODS

A systematic review of qualitative studies was conducted. Data bases were searched for qualitative research which explored participants' motivations for discontinuing medication and their experiences of the process.

RESULTS

Six themes were identified: (1) Taking medications: a loss of autonomy, (2) Discontinuing medication: a thought-out process, (3) Factors influencing the decision to discontinue medication, (4) Discontinuing medication: experiences of the process, (5) Outcomes of discontinuing medication, (6) Managing mental distress in the absence of medication.

CONCLUSION

Service providers need to be aware that for some service user's psychotropic medication is not deemed a suitable treatment approach. Those who wish to discontinue medication need to be supported in the context of positive, therapeutic risk where their mental and physical health can be monitored and the likelihood of success increased.

Understanding how personhood impacts consumers' feelings of safety in acute mental health units: a qualitative study

Being admitted to an acute mental health unit can lead to feelings of shame, and loss of personhood for some consumers. Promoting safety for consumers is a function of acute mental health units. This paper explores how consumers' personhood influences their perception and experience of safety in acute mental health units. Semi-structured interviews were conducted with 15 participants who had previously been admitted to an acute mental health unit. Thematic analysis was used to analyse the data. Participants perceived safety as being intrinsically linked to their personhood. When participants' innate worth was affirmed in their interactions with staff, participants felt safe. Three subthemes were identified: 'Seen as an equal', 'Being respected', and 'Able to make choices'. These findings can be used to inform nursing practices that enhance consumers' sense of personhood and, in so doing, promote consumers' safety and recovery in acute mental health units.

Using Q-methodology to explore mental health nurses' knowledge and skills to use recovery-focused care to reduce aggression in acute mental health settings

When nurses practise recovery-focused care, they contribute positively to the consumer's mental health recovery journey and empower the person to be actively engaged in the management of their illness. While using recovery-focused care is endorsed in mental health policy, many health professionals remain uncertain about its application with consumers who have a risk for aggression during their admission to an acute mental health inpatient setting. This paper reports on Australian research using Q-methodology that examined the knowledge and skill components of recovery-focused care that nurses use to reduce the risk for aggression. The data from forty mental health nurses revealed five factors that when implemented as part of routine practice improved the recovery outcomes for consumers with risk of aggression in the acute mental health settings. These factors were as follows: (I) acknowledge the consumers' experience of hospitalization; (II) reassure consumers who are going through a difficult time; (III) interact to explore the impact of the consumer's negative lived experiences; (IV) support co-production to reduce triggers for aggression; and (V) encourage and support consumers to take ownership of their recovery journey. These findings provide nurses with a pragmatic approach to use recovery-focused care for consumers with risk for aggression and contribute positively to the consumers' personal recovery.

Rethinking Risk Assessments in a Borderline Personality Disorder Unit: Patient and Staff Perspectives

Background

The present study was undertaken in a borderline personality disorder unit in Cambridge, UK. Our aim was to evaluate patient and staff perspectives on the current risk assessment procedure and to assemble opinions on a proposed change to this procedure.

Methodology

Structured interviews were conducted with patients and risk-assessing staff. Likert-scale and open questions were asked to gather both quantitative and qualitative data on both the preexisting risk assessment procedure and the proposed change to the procedure. The qualitative data was assembled into key themes.

Results

Patients and staff were moderately satisfied with the current risk assessment process, with patients scoring it an average of 2.75 out of 5 and staff scoring it 2.5 out of 5. Six key themes emerged as relevant to the process for both staff and patients: holistic approach, autonomy and freedom, responsibility, staff-patient relationship, time taken, and chance for reflection. One theme, “triggering negativity,” emerged among patients only, while a theme exploring ideas about risk emerged only among staff.

Conclusion

Our study highlights the need to introduce a new risk assessment procedure that grants patients more freedom and responsibility and encourages staff to individualize the process for each patient by taking a holistic approach. This would cultivate a ward environment that is less risk-averse and more recovery-oriented.

Exploring Therapeutic Risk in the Recovery Process of Adolescents at Risk of Self-harm: A Thematic Analysis of Support Staff Perceptions

Background and Objective:

The high prevalence of adolescent self-harm within mental health services presents considerable management concerns, exacerbated by a lack of clear evidence regarding therapeutically effective approaches. This shortfall perpetuates traditional risk-averse practice, despite likely inadequacies in mitigating self-harm through failing to address underlying psychological mechanisms. Therapeutic risk, defined as an approach whereby clinicians support individual risk-taking, may be an alternative that yields improved recovery outcomes. However, related research is adult-focused and provides limited detail on its features, practical delivery and impact on recovery. Consequently, the current study explored the experiences of professionals delivering a therapeutic risk ethos, including their conceptualisation of it and its impact on young people.

Methods:

Semi-structured interviews were conducted with seven mental health support workers employed by a residential healthcare provider, which promotes a therapeutic risk approach. The provider supported service users aged 15 - 20 experiencing complex psychopathology who, following inpatient discharge, presented a high risk of self-harm and suicidality. Interview data was thematically analysed.

Discussion and Conclusion:

Staff participants provided their understanding of a therapeutic risk approach, suggesting risk is viewed as positive and beneficial to recovery, alongside the promotion of service user freedom and flexible therapeutic risk management. The perceived therapeutic risk incorporates both permission and support, which facilitate the exploration of underlying feelings and alternative actions. Additionally, therapeutic risk promotes positive recovery outcomes due to empowered service users having increased control over their lives. They argued this can reduce psychological distress, encouraging the development of emotional regulation and adaptive coping strategies.

Attitudes towards dignity of risk in older people: A survey following a short narrative film

OBJECTIVE

To evaluate aged care staff's 'willingness to help an older person with risk-taking activities' that improve quality of life ('dignity of risk').

METHODS

Opportunity-based cross-sectional anonymous electronic survey in four Australian jurisdictions, conducted immediately after screening a short animated narrative film describing 'dignity of risk'. Survey comprised nine questions including respondent demographics, professional role, risk-taking and outcome.

RESULTS

From 24 separate screenings, there were 929 respondents. Agreement to 'help an older person with risk-taking activities' was associated with respondent prediction of the least severe harm occurring (OR = 2.22 [1.20, 4.12], P = .001). Conversely, respondents in non-executive, non-managerial roles-that is, nurses and care workers-were unlikely to agree to help with risk-taking activities (OR 0.36-0.49, P ≤ .03). There was not an association with respondent's age grouping (P = .6).

CONCLUSION

Staff self-reported attitudes towards dignity of risk are important to understand to enhance in an older person's quality of life.

Involving mental health consumers in nursing handover: A qualitative study of nursing views of the practice and its implementation

Nursing handover occurs between shifts and is an important means of communication and information exchange around consumer care. The involvement of consumers in nursing handover, known as 'bedside handover', is well established within general health settings and promotes a patient-centred approach to care. Bedside handover represents an opportunity for mental health settings to consolidate recovery-oriented principles, albeit with some unique challenges in the way that involving consumers in nursing handover is implemented. This qualitative descriptive study explores the views of nursing staff and nursing managers about involving consumers in nursing handover and the process of implementation across five mental health inpatient units in Australia. The study took place in a local health district covering regional and rural areas of New South Wales that had issued a directive to implement bedside handover. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study. Six focus groups were held with nursing staff (n = 22), and eleven individual interviews were undertaken with nursing managers to explore their perceptions of bedside handover and its implications for nursing practice. The data were analysed using thematic analysis. Data from focus groups and interviews were analysed separately and then combined to generate three themes: (i) the mental health context is different; (ii) protecting consumer privacy and confidentiality; and (iii) it might make things worse. The findings provide insights into both the challenges, and the process of involving consumers in nursing handover within mental health settings and provides guidance for future implementation.

Role of artificial intelligence and enterprise risk management to promote corporate entrepreneurship and business performance: evidence from korean banking sector

Korean banking industry has achieved significant growth in financial market, however, these banks are lacking with entrepreneurship activities due to low information system risk management. Objective of this study is to examine the effect of artificial intelligence, information system risk management and corporate entrepreneurship on business performance of Korean banks. The current study introduced artificial intelligence as one of the elements to boost risk management activities, corporate entrepreneurship and business performance. This objective was achieved through a research survey among Korean banks. Questionnaires were distributed among the employees of banks by using simple random sampling. Partial Least Square (PLS)-Structural Equation Modeling (SEM) was used for data analysis. Results of the study revealed that artificial intelligence has key role to influence information system risk management. It has positive role to enhance information system risk management practices. Information system risk management practices has vital importance to promote corporate entrepreneurship which increases the business performance of banks. This study is important for Korean banks to make various strategies for risk management, corporate entrepreneurship and business performance.

Facilitating pathways to care: A qualitative study of the self-reported needs and coping skills of caregivers of young adults diagnosed with early psychosis

WHAT IS KNOWN ON THE SUBJECT?: In clinical psychiatry and mental health nursing practice, family caregivers are known to provide the bulk of care and play an important role in facilitating recovery outcomes for their loved ones diagnosed with psychosis. Providing services and interventions to family caregivers is as important as to patients in the early stage of psychotic experience for having a beneficial impact on the patients' clinical and social outcomes. Limited qualitative research has focused on family caregivers' subjective views of what they need during the critical period to identify early warning signs and connect their loved ones to professional help as they have no prior experience in caring for persons with psychosis. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Using qualitative analysis of family caregiver focus groups, this manuscript provides readers in clinical nursing practice with an understanding of family caregivers' lived experiences of supporting their loved one diagnosed with early psychosis. Understanding family caregivers' caregiving unmet needs in supporting their loved one diagnosed with early psychosis could inform both the technology-assisted intervention development and nursing practice in improving family-centred care and facilitate self-management practice. IMPLICATIONS FOR MENTAL HEALTH NURSING: Psychiatry and mental health nursing has long been engaged with the health and well-being of individuals with psychosis and supporting their families in the development, evaluation and implementation of innovative approaches to patient and family education. Digital technologies designed to deliver tailored intervention for family caregivers are underdeveloped, and the present study identifies a number of potential features that could comprise technology to meet the needs of this population. ABSTRACT: Introduction Caregivers play a critical role in detecting and managing psychotic symptoms before young people diagnosed with early psychosis present to care. Little is known about the specific needs of caregivers in navigating pathways to care for their loved one. Aim The purpose of this study was to understand the needs of family caregivers and their ways of coping on the pathway to care for early psychosis. Method Twenty family caregivers of individuals diagnosed with early psychosis participated in three focus groups that explored caregiving needs provision for early psychosis. Thematic analysis was conducted. Results We identified four major themes: education and skill training; raising wider awareness, such as police offers and teachers; adopting technologies for coping; and effective coping strategies. Implications for practice These findings provide important insights into caregiving needs and the ways for nurses to address those needs and better equip carers to recognize early symptoms, monitor behaviour changes and navigate care to support people with first-episode psychosis. Nursing researchers can use the information to develop on-demand and tailored family-centred intervention in addressing caregivers' needs in education, increasing awareness of early psychosis and fostering effective coping strategies.

Bucking the system: Mitigating psychiatric patient rule breaking for a safer milieu

This article examines patients' understandings of rule breaking in the hospital setting. This work is important to inpatient psychiatric nursing because considering patients' perspectives about their own rule breaking can help nurses provide more therapeutic and safer patient care. The study finds that rule breaking behaviors are often a manifestation of patient resistance to institutionalization and loss of power. These behaviors are also related to nursing practice, as patients closely observe staff and look for gaps in the system to get away with or circumvent the rules. These findings suggest rule breaking behaviors can be reduced not by trying to further curtail the patient's autonomy but, rather, by changing the rules and/or how they are administered by staff to accommodate patients' perspectives and needs for freedom. Also, nurses must be clear in communicating with patients about the rationale for rules, and be consistent in how they enforce them.

'I know what I need to recover': Patients' experiences and perceptions of forensic psychiatric inpatient care

Patients find forensic psychiatric care inadequate in that they are not treated as individuals and not involved in their own care. The purpose of this study was to describe patients' experiences and perceptions of forensic psychiatric inpatient care. Semi-structured interviews were conducted with 11 inpatients. A qualitative content analysis resulted in a recurring theme, 'I know what I need to recover', and three main categories: 'A need for meaning in a meagre existence', 'A need to be a person in an impersonal context', and 'A need for empowerment in a restricted life'. Participants experienced and perceived forensic care as predominantly monotonous, predetermined, and not adapted to them as individuals, forcing them to fight and adapt to get through it and not lose themselves. Perceived needs were largely ignored or opposed by staff due to the content and structure of care. Findings suggest a need for reflective practices and patient involvement in order to develop and maintain a person-centred and recovery-oriented nursing practice. The study adds to previous research showing the importance of patients in forensic psychiatric inpatient care being listened to and involved in their care. The study is reported in accordance with the COREQ guidelines.

Engaging with nurses to develop an occupational violence risk assessment tool for use in emergency departments: A participatory action research inquiry

BACKGROUND

Early detection of occupational violence (OV) risk factors could facilitate timely and appropriate management of patients in the emergency department. For this purpose, an OV risk assessment could be useful and best initiated at triage.

AIMS

To understand the need for and determine potential utility and desirable components of an OV risk assessment tool; and to determine specific challenges to its implementation if appropriate.

METHODS

A participatory action research was conducted. Data were collected through focus groups and semi-structured interviews. Thematic analysis was done inductively and collaboratively using Braun and Clarke's technique.

FINDINGS

Six themes were identified from triage nurses (N = 15) pertaining to: i) OV risk assessment; ii) communication of OV risk; iii) clinical implications of risk assessment; iv) tool attributes; v) future implementation challenges; vi) unintended consequences.

CONCLUSION

The development of an OV risk assessment tool is supported, but with very specific attributes. Findings herein also have implications on the implementation and evaluation of this tool in emergency settings.

Disclosure of confidential information by mental health nurses, of patients they assess to be a risk of harm to self or others: An integrative review

There is a duty of confidentiality on the part of mental health nurses when they handle confidential patient information. Nonetheless, it may be necessary to disclose confidential information of a patient if the patient is assessed as being a risk to self or others, to protect the patient or others from harm. However, disclosing information inappropriately may constitute a breach of confidentiality. There is a paucity of information on how mental health nurses understand the rules of confidentiality when deciding to withhold or disclose confidential information in these circumstances. An integrative review of the literature was undertaken to explore the disclosure of confidential information by mental health nurses when they assess a patient as being a risk of harm. The findings indicate the rules of confidentiality are not well understood, or are not adhered to by mental health nurses. Risk assessments were found to underpin deliberations to withhold or disclose confidential information of a patient, despite risk being difficult to predict with any certainty. For risk assessment, mental health nurses were noted to prefer their unstructured clinical judgement over actuarial methods; and defer to their clinical intuition over scores of a structured risk assessment instrument, when making structured clinical judgement-backed decisions in this area of their practice. Gaps in the literature that may be addressed by future empirical research were revealed during this integrative review.

Recovery-Oriented Reflective Practice Groups: Conceptual Framework and Group Structure

The recovery-oriented reflective practice group (RORPG) is a staff-directed intervention aimed at achieving the recovery-focused transformation of mental health settings. This discussion paper aims to outline and reflect on the conceptual framework and group structure of recovery-oriented reflective practice groups. RORPGs build on conceptualizations of reflective practice, personal recovery, mental health nursing as a relational and reflective practice, and abductive reasoning. Dewey's phases of reflection, together with an understanding of nursing practice as a dynamic process of care, provide a structure for group sessions in which abductive reasoning can be considered a core activity. This paper outlines a sound theoretical foundation and suggests that RORPGs might prove useful for providing a space for learning in practice, informed by both theoretical and practical knowledge.

'There is no progression in prevention' - The experiences of mental health nurses working with repeated self-harm

Caring for people who self-harm is an everyday experience for mental health nurses and an important part of their role. How mental health nurses respond to and support those who self-harm can have a significant impact on the outcomes for service users and their intentions to seek help in the future. Repeated self-harm can be a particularly challenging phenomenon as it is often misunderstood and can have a negative impact on the therapeutic relationship. This qualitative descriptive study aims to explore how mental health nurses understand and work with repeated self-harm. Nine nurses working in a range of mental health settings within one service participated in semi-structured interviews which were analysed thematically. Findings are presented in two themes exploring participants' perceptions and understanding of repeated self-harm, and the process of learning to work with repeated self-harm, and are reported in accordance with the consolidated criteria for reporting qualitative research guidelines (COREQ). Participants reported that nursing practice relating to repeated self-harm remains largely focused on maintenance of safety and prevention of self-harm despite the identification that this often does not work. It was accepted that there is sometimes a lack of understanding about the function of self-harm; however, participants reported understanding increased following specific education about self-harm. Participants also identified the potential for more empowering and recovery-orientated responses, including the utilization of harm reduction approaches, to the care of those who repeatedly self-harm.

'Promoting and preserving safety and a life-oriented perspective': A qualitative study of nurses' interactions with patients experiencing suicidal ideation

Suicide prevention is an important imperative in psychiatric hospitals, where nurses have a crucial role in and make essential contributions to suicide prevention and promoting the recovery of patients experiencing suicidal ideation. The present qualitative grounded theory study aimed to uncover and understand the actions and aims of nurses in psychiatric hospitals during their interactions with patients experiencing suicidal ideation. Interviews were conducted with 26 nurses employed on 12 wards in four psychiatric hospitals. The data analysis was inspired by the Qualitative Analysis Guide of Leuven. The findings show that nurses' actions and aims in their interactions with patients experiencing suicidal ideation are captured in the core element 'promoting and preserving safety and a life-oriented perspective'. This core element represents the three interconnected elements 'managing the risk of suicide', 'guiding patients away from suicidal ideation', and 'searching for balance in the minefield'. The enhanced understanding of nurses' actions and aims can inform concrete strategies for nursing practice and education. These strategies should aim to challenge overly controlling and directing nursing approaches and support nurses' capacity and ability to connect and collaborate with patients experiencing suicidal ideation.

The Administration of Pro re nata Medication by Mental Health Nurses: A Thematic Analysis

Pro re nata (PRN) medication is medication administered by nurses as required commonly in response to a patient's symptoms or behaviour including insomnia, agitation or anxiety. There is a paucity of research around the process of PRN administration in mental health settings in Ireland and international evidence suggests inconsistencies in practices. This study aimed to explore the process of PRN medication administration by mental health nurses. Using a qualitative descriptive design, semi-structured interviews were undertaken with 19 mental health nurses in three acute inpatient units in one mental health service in Ireland. Most participants reported undertaking an assessment of the patient before administering PRN medication; however, many also reported having observed incidents of poor practice. There was evidence of some interdisciplinary sensitivities around instructions regarding the use of PRN medications between doctors who prescribed them and nurses who dispensed them. A need for service improvements were also identified including the use of alternative strategies to PRN use such as de-escalation techniques and education around psychopharmacology. PRN medication is commonly used in mental health settings; however, this study suggests that there is potential for improvement in relation to how it is prescribed and administered. Overuse of PRN medication has been associated with increased morbidity. Mental health nurses are required to carefully consider whether PRN medication is warranted in the first instance and how its use might impact on patients.

Patient perspectives of helpful risk management practices within mental health services. A mixed studies systematic review of primary research

WHAT IS KNOWN ABOUT THE SUBJECT?: Risk in psychiatry involves harm to self or others owing to mental health difficulties, for example iatrogenic effects of treatment, self-harm, suicide and violence. Risk management is a framework to minimize risks, comprising of risk assessment, generation of risk management plans and evaluation of interventions. Literature has extensively explored risk management and presented a critique that its practices can lead to patient harm. However, there is a paucity of literature about what patients identify as helpful risk management practices, despite the potential for such patient views to ameliorate harm and improve mental health care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: Interpersonal relationships with clinicians, and communication that keeps patients involved and informed of management processes, were found to be central to beneficial risk management practices, while patients having agency and autonomy to influence their participation was also important. Beneficial interpersonal relationships and connectivity in the form of patients' wider community of support were found to be influential in aiding risk management. Meaningful relationships, and particularly peer support, that maintained personal and collective identities were prevalent in the literature. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Rendering risk management more visible and accessible in practice might cultivate an openness that promotes patient participation. This includes drawing on a wider network of support, for example the patient's friends and family, as well as having advocacy utilizing peer support. Abstract Introduction Minimizing the harm that patients pose to themselves and others, due to mental health difficulties, is a central component of risk management in psychiatry. However, risk management itself can cause patient harm, but despite this and the potentially informative value of lived experience, little is known about what patients want or expect from risk management. Aim To review research and explore what patients consider beneficial in risk management practice. Method A mixed studies systematic review utilizing PRISMA guidelines, alongside a convergent qualitative design to categorize findings. Results Twelve papers were identified, generating two categories of beneficial practices: interpersonal relationships and communication with clinicians; coupled with patient agency in their own risk management. Discussion Connectivity appears important. Particularly patients feeling involved, and their voices being heard in both the identification of risks and then shaping risk management practice. Moreover, this included involvement of friends, family and peers to widen input and supportive networks beyond clinical relationships. Implications for Practice Risk management needs to be an accessible part of care, which is more inclusive of patient views and needs. The latter might also be aided by drawing on the patient's wider community in order to provide more effective support and risk management.

The transition from patient to mental health peer worker: A grounded theory approach

Peer workers are increasingly being engaged in contemporary mental healthcare. To become a peer worker, patients must evolve from having a patient identity to a peer worker identity. This study aims to understand how mental health peer workers experience their transition and how it affects their view of themselves and their direct working context. A grounded theory approach was used. Seventeen mental health peer workers in Belgium were recruited through theoretical sampling. Semi-structured interviews were conducted and analysed according to the constant comparative method. The results indicate that novice peer workers experience peer work as an opportunity to liberate themselves from the process of mental suffering and realise an acceptable form of personal self-maintenance. As peer workers become more experienced, they are confronted with external factors that influence their self-maintenance and personal development. Experiencing clarity in their duties and responsibilities, equality, and transparency in the workplace reinforce their experience of self-maintenance and positively influence their self-development. Experiencing a lack of clarity in their duties and responsibilities, inequality, and lack of openness discourage peer workers' self-development process. These experiences challenge their personal motivations to become peer workers, which are usually linked to building a meaningful life for themselves. The insights can encourage organisations to build up a supportive environment collaboratively with peer workers and ensure that peer workers can exert their authentically unique role in mental healthcare.

Rapid tranquilization: An audit of Irish mental health nursing practice

Rapid tranquillization is a pharmacological intervention sometimes employed in mental health care for the management of acute behavioural disturbance. It is a form of restrictive practice, which, along with seclusion and restraint, is a conventional and controversial intervention in the therapeutic management of risk in mental health settings. This study surveyed mental health nurses practice in rapid tranquillization. A self-report questionnaire was utilized which addressed aspects such as definitions of rapid tranquillization, presence of rapid tranquillization policy, types of incidents where it is used and postintervention monitoring. The results demonstrate that rapid tranquillization is an intervention used in the management of acute behavioural disturbance in various mental health settings in Ireland. Respondents showed a basic understanding of rapid tranquillization as an intervention; however, some areas reported not having a specific rapid tranquillization policy. There was some evidence of a variation in postrapid tranquillization monitoring of psychiatric/mental health and physical health. Service user debriefing following rapid tranquillization was reported to be common; however, the content of this was not elaborated on. In the light of variations in practice, specific training and the development of rapid tranquillization policies are recommended.

Patient safety on psychiatric wards: A cross-sectional, multilevel study of factors influencing nurses' willingness to share power and responsibility with patients

The World Health Organization highlights the need for more patient participation in patient safety. In mental health care, psychiatric nurses are in a frontline position to support this evolution. The aim of the present study was to investigate the demographic and contextual factors that influence the willingness of psychiatric nurses to share power and responsibility with patients concerning patient safety. The patient participation culture tool for inpatient psychiatric wards was completed by 705 nurses employed in 173 psychiatric wards within 37 hospitals. Multilevel modelling was used to analyse the self-reported data. The acceptance of a role wherein nurses share power and responsibility with patients concerning patient safety is influenced by the nurses' sex, age, perceived competence, perceived support, and type of ward. To support nurses in fulfilling their role in patient participation, patient participation-specific basic and continuing education should be provided. Managers and supervisors should recognize and fulfil their facilitating role in patient participation by offering support to nurses. Special attention is needed for young nurses and nurses on closed psychiatric wards, because these particular groups report being less willing to accept a new role. Ward characteristics that restrict patient participation should be challenged so that these become more patient participation stimulating. More research is needed to explore the willingness and ability of psychiatric nurses to engage in collaborative safety management with patients who have specific conditions, such as suicidal ideation and emotional harm.

Preparing master-level mental health nurses to work within a wellness paradigm: Findings from the eMenthe project

Mental health promotion remains an important component of mental health nursing practice. Supporting wellness at both the individual and societal levels has been identified as one of the key tenets of mental health promotion. However, the prevailing biomedical paradigm of mental health education and practice has meant that many nurses have not been equipped to incorporate a wellness perspective into their mental health practice. In the present study, we report on an exploratory study which details the knowledge, skills, and attitudes required by master-level mental health nurses to practice within a wellness paradigm from the perspective of three groups of key stakeholders: (i) service users and family members (n = 23); (ii) experienced mental health nurses (n = 49); and (iii) master-level mental health nursing students (n = 37). The findings, which were reported from individual and focus group interviews across five European countries, suggested a need to reorientate mental health nursing education to include a focus on wellness and resilience to equip mental health nurses with the skills to work within a strengths-based, rather than a deficits-based, model of mental health practice. Key challenges to working within a wellness paradigm were identified as the prevailing dominance of the biomedical model of cause and treatment of mental health problems, which focusses on symptoms, rather than the holistic functioning of the individual, and positions the person as passive in the nurse-service user relationship.

Towards relational recovery: Nurses' practices with consumers and families with dependent children in mental health inpatient units

Facilitating parent-child and family connections during parental hospitalization provides important opportunities for mental health services to support individual and family recovery. Nurses are often the primary point of contact for families in the inpatient context. They play an integral role in the care provision of consumers and families and in supporting consumers' recovery. The aim of the present qualitative study was to explore nurses' practice with families in inpatient mental health settings in the context of designated family rooms. Three themes were derived from the thematic analysis of semistructured interviews with 20 nurses from four mental health inpatient units. Nurses experienced tensions within their roles in balancing safety and risk, a lack of confidence in family-focused practices in relation to role expectations, and challenges in juggling nursing care ideals with the contemporary realities of inpatient practice. A family-centred relational recovery approach is recommended for mental health services, which is underpinned by family-focused policies and processes, and supported at an organizational, managerial, and local-unit level. At an individual level, nurses need professional development on the models of care they practice in, explicit role clarity on their practice with families, and education on evidence-based brief family interventions.

The experience of being a psychiatric nurse in South Africa: A qualitative systematic review

PURPOSE

The purpose of the study was to summarize the experiences of African psychiatric nurses in their workplace by examining the findings of existing qualitative studies.

METHODS

Eleven studies published in English, Portuguese, and Spanish, between 1998 and 2016, which explored psychiatric nurses' experiences in Africa, were included.

FINDINGS

After meta-aggregation, five key findings were identified: 1) organization and management, 2) perceptions of professional safety and insecurity, 3) relationship with the patient, 4) emotional experiences and 5) recommendations for improvement.

DISCUSSION

The findings in this study highlight the stressful nature of the work climate of the psychiatric nurse in South Africa. More focus on improving working conditions and providing support is necessary to increase the quality of care for psychiatric mental health patients and their nurse providers.

Therapeutic risk-taking: A justifiable choice

Taking risks is a fundamental part of the human experience that supports personal growth. Therapeutic risk-taking enables patients to make decisions about their level of safety and to pursue goals. Promoting therapeutic risk-taking can be complex. Professionals can experience tension striving for a balance between the interests of the individual and societal pressures to control risk. This article examines therapeutic risk-taking, recognising the challenges to supporting it in practice and debating how they may be overcome.

Learning Objectives

• Be able to explain what therapeutic risk-taking is and discuss its application to psychiatric practice

• Understand the factors that challenge and enable therapeutic risk-taking in psychiatric practice

• Describe the association between therapeutic risk-taking and recovery

Measures for screening for intimate partner violence: a systematic review

WHAT IS KNOWN ON THE SUBJECT?: Intimate partner violence (IPV) has a significant impact on the onset, duration and recurrence of mental health problems. Prevalence rates of IPV are significantly higher in mental health services, but the studies are limited. Accurate assessment of IPV is important for decision making in risk assessment and safety planning within mental health nursing. Psychometrically tested tools are the most accurate way to identifying all areas of IPV abuse: physical, sexual and psychological. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Ten IPV screening tools were identified in healthcare and three tools; Women Abuse Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation, Afraid, Rape and Kick (HARK) were identified as having strong psychometric values as they assessed all areas of IPV and were validated against an appropriate reference standard. None of the three IPV tools identified (WAST, AAS, HARK) were tested on men or in mental health settings impacting the gender sensitivities of the tools and the reliability of the prevalence rates of IPV in mental healthcare. Over seventy percent of the studies reviewed were conducted in America this impacts the cultural sensitivities of the IPV tools. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: IPV screening needs to be incorporated as a priority in mental health services in order to reduce the morbidity and mortality issues associated with this abuse. Psychometric tools to screen for IPV need to be incorporated to assist mental health professionals in decision making in risk assessment and safety planning. Further research is needed to improve the psychometric properties of IPV tools in mental health settings, to ensure they are culturally and gender sensitive.

ABSTRACT

Objective Intimate partner violence (IPV) is a public health priority due to the physical and mental impacts it has on health. No existing reviews have focused on the psychometric properties of IPV screening tools used to screen men and women within a mental health context. This review aimed to identify the best psychometrically tested screening tools available to assess all areas of IPV in men and women in mental health setting. Method Databases psycArticles, PsycINFO, Social Science, CINAHL, PubMed and Cochrane were searched from their starting date through to July 2015. Eligible studies were published in peer-reviewed publications in English. Results Thirty-six studies met the inclusion criteria. Ten IPV screening tools were identified. Three tools assessed all areas of IPV and were validated against an appropriate reference standard. One study tested IPV screening tool in a mental health setting. Conclusion Mental health nurses need to incorporate a psychometrically tested IPV tool as part of risk assessment and safety planning for clients. This review identified three tools that are suitable for identifying IPV in a mental health context. However, further research is necessary to validate IPV screening tools that are culturally sensitive and have been validated with men and women.

Survey of mental health nurses' attitudes towards risk assessment, risk assessment tools and positive risk

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and safety planning are a core aspect of the role of the mental health nurse. Conflicting views exist on the value of risk assessment tools. Few studies have examined mental health nurses' attitudes towards risk, including use of tools and the role of positive risk in recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Mental health nurses view risk assessment as a core dimension of their role and not merely an exercise to fulfil organizational clinical safety and governance obligations. The majority of nurses hold positive attitudes towards therapeutic or positive risk, and consider creative risk taking as vital to people's recovery. The majority of nurses believe that risk assessment tools facilitate professional decision making, however, some are concerned that tools may negatively impact upon therapeutic relationships. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Ongoing education on the use of risk assessment tools is required to minimize views that their use is incompatible with therapeutic engagement, and to enable nurses to develop confidence to engage with positive risk and to allow service users make decisions and take responsibility.

ABSTRACT

Introduction Risk assessment and safety planning are considered core components of the role of the mental health nurse; however, little is known about nurses' attitudes towards risk assessment, use of tools to assess risk or therapeutic risk taking. Aim This study aimed to explore mental health nurses' attitudes towards completing risk assessments, use of tools as an aid, and therapeutic or positive risk. Method An anonymous survey which included 13 attitudinal statements, rated on a five-point Likert scale, was completed by 381 mental health nurses working in adult services in Ireland. Findings Findings indicate strong support for the practice of risk assessment in mental health practice. The vast majority of nurses believe that risk assessment tools facilitate professional decision making; however, there is concern that the use of these tools may negatively impact upon therapeutic engagement with service users. The majority of participants have positive attitudes towards therapeutic risk, believing that service users have the right to take informed risks in the context of recovery-orientated care. Discussion The provision of education on the use of risk assessment tools within the context of engagement may help minimize views that the use of assessment tools are incompatible with therapeutic engagement.