'What would a trauma-informed mental health service look like?' Perspectives of people who access services

Under Prepared for Practice: A Qualitative Study of Mental Health Nurse Undergraduate Workforce Preparation in Australia

Internationally there are both current and looming mental health workforce shortages. Mental health nurses who have received specialist education are a vital component to respond to these challenges.

AIM

This qualitative study aimed to better understand the efficacy and product quality of mental health nurse workforce preparation through pre-registration nurse education in Australia.

METHOD

To meet this aim 19 educators representing 13 different universities were qualitatively interviewed.

RESULTS

Thematic analysis found four themes (1) Graduates are under-prepared for safe mental health nurse practice; (2) Essential mental health nurse capabilities are missing in graduates; (3) Barriers to graduate preparation, and (4) Negative impacts of inadequate graduate preparation.

DISCUSSION

Findings from this study suggest future workforce shortages would be best addressed through direct undergraduate entry for mental health nursing Implications for Practice: All nurse undergraduate training needs significantly enhanced mental health theory and placement within the course.

Two people making sense of a story: narrative exposure therapy as a trauma intervention in early intervention in psychosis

Background: Narrative exposure therapy (NET) is a recommended intervention for people with multiple trauma histories; however, research is lacking into its use with people experiencing psychosis, many of whom report multiple trauma histories.Objective: This study aimed to explore experiences of NET in early intervention in psychosis (EIP) services.Method: Eight clinicians and four experts with lived experience (experts by experience) of psychosis and multiple trauma were interviewed on a single occasion using two versions (clinician and expert by experience) of a semi-structured interview schedule. Data was analysed using thematic analysis.Results: Five overarching themes were generated, relating to fear and avoidance of memories, importance of trust, organizing memories and making new meaning, reconnecting with emotions, and considerations when delivering NET in EIP.Conclusions: Directly addressing the impact of multiple trauma in people experiencing first episode psychosis is frightening and emotive, but helps to address painful memories and organize them into a personal narrative. Increases in distress and anomalous experiences were carefully considered by clinicians, but typically outweighed by the benefits of NET. Challenges were comparable to those described in non-psychosis research. Implications for clinical practice and future research are outlined.

In their own words: Mental health nurses' experiences of trauma-informed care in acute mental health settings or hospitals

Trauma-informed care has emerged as a prominent strategy to eliminate coercive practices and improve experiences of care in mental health settings, with advocacy from international bodies for mental health reform. Despite this, there remains a significant gap in research understanding the integration of trauma-informed care in mental health nursing practice, particularly when applied to the acute mental health or hospital-based setting. The study aimed to explore the experiences of mental health nurses employed in acute hospital-based settings from a trauma-informed care perspective. The study design was qualitative, using a phenomenological approach to research. A total of 29 nurses employed in acute mental health or hospital-based environments participated. Three over-arching themes were uncovered: 'Embodied Awareness': highlighting mental health nursing emotional capabilities are deeply rooted in bodily awareness. 'Navigating Safety': signifying spatial elements of fear and how some mental health nurses' resort to coercive or restrictive practices for self-preservation. 'Caring Amidst Uncertainty': revealing the relational influences of security guards in mental health nursing. The study reveals a significant gap in trauma-informed care implementation when applied to the context of mental health nursing practice in this setting. Limited evidence on trauma-informed care for mental health nurses, coupled with inadequate workforce preparation and challenging work environments, hinder the effective integration of it. To genuinely embed TIC in acute mental health settings, the study emphasises the need for a thorough exploration of what this entails for mental health nurses.

Discourses of compassion from the margins of health care: the perspectives and experiences of people with a mental health condition

BACKGROUND

Evidence supports the positive influence of compassion on care experiences and health outcomes. However, there is limited understanding regarding how compassion is identified by people with lived experience of mental health care.

AIM

To explore the views and experiences of compassion from people who have lived experience of mental health.

METHODS

Participants with a self-reported mental health condition and lived experience of mental health (n = 10) were interviewed in a community setting. Characteristics of compassion were identified using an interpretative description approach.

RESULTS

Study participants identified compassion as comprised three key components; 'the compassionate virtues of the healthcare professional', which informs 'compassionate engagement', creating a 'compassionate relational space and the patient's felt-sense response'. When all these elements were in place, enhanced recovery and healing was felt to be possible. Without the experience of compassion, mental health could be adversely affected, exacerbating mental health conditions, and leading to detachment from engaging with health services.

CONCLUSIONS

The experience of compassion mobilises hope and promotes recovery. Health care policymakers and organisations must ensure services are structured to provide space and time for compassion to flourish. It is imperative that all staff are provided with training so that compassion can be acquired and developed.

Trauma-Informed Care in Acute Adult Public Mental Health Settings: A Scoping Study Examining Implementation

Trauma-informed care (TIC) is not a new concept. Despite TIC being at the forefront of international acute public mental health services policy, and researched since 2006, implementation has been hampered. This paper reports findings from a scoping study examining clinical and lived experience workers experience of TIC in Acute Adult Public Mental Health Services. In this scoping study five databases and grey literature were scanned in 2021 and updated in 2023, to address the question: What is known about TIC concerning the clinical and mental health lived experience workforce in the acute adult public mental health service? Forty-six papers met the inclusion criteria. Analysis revealed commitment in conceptualisation of TIC in mental health policy, requirements for incorporating TIC in acute adult mental health care, and barriers to implementation, including dissonance towards role expectations. The literature calls for investment in implementing TIC, which includes an increased workforce consisting of mental health lived experience workers, clinical staff with TIC knowledge and skills, and specialist TIC experts. Further research is needed to understand more fully the opportunities and barriers to implementing TIC in acute public mental health settings.

An evaluation of a trauma-informed educational intervention to enhance therapeutic engagement and reduce coercive practices in a child and adolescent inpatient mental health unit

High-risk behaviours are sometimes encountered in Child and Adolescent inpatient mental health units and can prompt the use of coercive practices to maintain safety. Coercive practices may lead to re-traumatisation of young people and deteriorating therapeutic relationships. Trauma-informed practice (TIP) has successfully reduced coercive practices. While education is identified as foundational to implementation, evaluations of programmes remain minimal. The aim of this study was to explore mental health professionals' views and experiences of a trauma-informed education programme and its likely impact on their approach to practice. Five mental health professionals agreed to participate, four contributed in a focus group and one in an individual interview. Data were analysed thematically using the Braun and Clarke Framework. Three main themes were identified. Firstly, shifting attitudes and perceptions of trauma-informed practice. Participants believed they had developed more compassion towards clients and these attitudes were reflected in their clinical practice. Secondly, challenges associated with trauma-informed practice educational intervention. Staffing issues and shift work made it difficult for participants to attend education sessions regularly. Participants identified barriers to practicing in a trauma-informed manner in the current clinical environment. Finally, the need for interdisciplinary communication and support was identified. Participants saw the need for all professionals, not only nurses, to take responsibility for changing practice, and for stronger support at the organisational level. Trauma-informed practice is crucial to recovery-focused mental health nursing practice. These findings highlight the importance of TIP education and suggest areas for further improvement to enhance positive mental health outcomes for young people.

Using a trauma-informed care framework to explore social climate and borderline personality disorder in forensic inpatient settings

Tensions between therapeutic and security needs on forensic wards can create a social climate which is challenging for both mental health nurses and patients. Social climate refers to the physical, social and emotional conditions of a forensic ward which influence how these environments are experienced. For patients with borderline personality disorder (BPD), previous trauma means that the social climate of forensic settings may be experienced as retraumatising, negatively impacting the outcomes and wellbeing of both patients and mental health nurses. Trauma-informed care (TIC) has been offered as a contemporary framework for mental health nursing in inpatient units which aims to create a therapeutic social climate. In this critical review, we drew widely on literatures examining the social climate in forensic settings, the relationships between patients with BPD and staff (including mental health nurses), and the experiences of patients with BPD in forensic and inpatient settings to draw out the implications of scrutinising these literatures through the lens of TIC. Attending to the physical, social and emotional conditions of social climate in secure settings highlights how forensic wards can mirror trauma experiences for patients with BPD. Implementing TIC in these contexts has the potential to evoke positive shifts in the social climate, thus reducing the risk of retraumatisation and leading to improved outcomes for patients and staff.

Experiences of violence among people with stimulant use disorder in psychiatric inpatient settings: A qualitative study

OBJECTIVE

To describe the perspectives of those with lived experience of stimulant use disorder on methamphetamine-related violence in psychiatric inpatient settings.

METHOD

Eight adult psychiatric inpatients with stimulant use disorder were recruited. Semi-structured interviews were recorded, transcribed and analysed using thematic analysis.

RESULTS

Participants reported that traumatic experiences predisposed those using methamphetamine to violent behaviour. Participants were fearful of psychiatric hospitalisation because of loss of autonomy and stigma. Methamphetamine use was associated with mercurial intense emotions. Participants believed these factors led to violence during psychiatric admissions.

CONCLUSIONS

People with stimulant use disorder have a sophisticated understanding of the complex causal pathways from methamphetamine use to violent behaviour. Their lived experience can make an important contribution to service development.

The physical health nurse consultant and mental health consumer: An important therapeutic partnership

People diagnosed with mental illness (hereon referred to as consumers) experience a disproportionately lower life expectancy of up 30 years compared to the general population. Systemic issues such as diagnostic overshadowing and stigma from healthcare professionals have inhibited the development of positive therapeutic partnerships that enable consumers to seek and engage support for their physical health concerns. Consumers have called for healthcare professionals to skillfully develop and prioritize therapeutic partnerships whilst coordinating and providing physical healthcare. The aim of this qualitative descriptive research was to explore consumer views and experiences of their interactions with a specialist mental health nursing role, the Physical Health Nurse Consultant. Semi-structured interviews were conducted with 14 consumers from a large public Community Mental Health Service in the Australian Capital Territory. Interviews were transcribed and thematically analysed. Therapeutic partnerships were an overarching theme identified from the data and included three sub-themes: personal attributes of the Physical Health Nurse Consultant; behaviour change engagement strategies; and impact of the therapeutic partnership. Consumers described the personal and professional attributes of the Physical Health Nurse Consultant that enabled the establishment and maintenance of their highly valued therapeutic partnership. This therapeutic partnership was perceived to positively impact their personal and clinical outcomes. With increasing support from consumers, clinical practice settings should move towards embedding a Physical Health Nurse Consultant role in routine practice. Further research exploring the co-development of health behaviour change goals and, barriers and facilitators experienced by the consumers regarding the Physical Health Nurse Consultant is required to further role development.

The impact of trauma-informed suicide prevention approaches: A systematic review of evidence across the lifespan

Trauma is associated with an increased likelihood of experiencing suicidality, indicating the need for and potential value of trauma-informed suicide prevention strategies. The aim of this study is to systematically review published literature regarding trauma-informed approaches for suicide prevention, and the impact on suicide outcomes. Systematic searches were conducted in eight databases (Medline, Embase, PsycInfo, Emcare, Nursing, and JBI in the Ovid platform; as well as ProQuest Psychology Database and The Cochrane Library) in March 2022, with no publication date limit. Four studies met the inclusion criteria: two randomized controlled trials and two quasi-experimental studies. Two studies reported reductions in ideation, intent, and behaviour among youth and a cultural minority group. Few studies directly reporting suicide outcomes were identified, all were quantitative, and heterogeneity prevents generalizability across population groups. Currently, there is limited evidence focusing specifically on trauma-informed suicide prevention across the lifespan. Additional research, incorporating lived experience voices, is needed to understand the potential of this approach, as well as how mental health nurses can incorporate these approaches into their practice.

Trauma-informed care in acute mental health units through the lifeworld of mental health nurses: A phenomenological study

Trauma-informed care has gained increasing popularity in mental health services over the past two decades. Mental health nurses remain one of the largest occupations employed in acute mental health settings and arguably have a critical role in supporting trauma-informed care in this environment. Despite this, there remains a limited understanding on how trauma-informed care is applied to the context of mental health nursing in the hospital environment. The aim of this study was to explore what it means for mental health nurses to provide trauma-informed care in the acute mental health setting. The study design was qualitative, using van Manen's (Researching lived experience: human science for an action sensitive pedagogy. State University of New York Press, 1990) approach to hermeneutic phenomenological inquiry. A total of 29 mental health nurses participated in this study. There were three overarching themes that emerged; these entail: embodied trauma-informed milieu, trauma-informed relationality and temporal dimensions of trauma-informed mental health nursing. The study found that for mental health nurses, there are elements of trauma-informed care that extend far beyond the routine application of the principles to nursing practice. For mental health nurses working in the acute setting, trauma-informed care may offer a restorative function in practice back to the core tenants of therapeutic interpersonal dynamics it was once based upon.

"They may be confronting but they are good questions to be asking" young people's experiences of completing a trauma and PTSD screening tool in an early psychosis program

BACKGROUND

There is a history of inadequate enquiry about, and assessment of, trauma in young people within Early Psychosis services and even when screening does occur there is little known about how young people experience this process.

AIMS

This study aimed to explore young people's experiences of completing a trauma and PTSD screening tool when receiving a service in an Early Psychosis Program.

METHOD

Semi-structured interviews were conducted with 10 young people, aged 18-24 years, to explore their subjective experience of this process. Transcripts were analysed via interpretative phenomenological analysis.

RESULTS

Four super-ordinate themes were identified: (i) an emotional experience, (ii) the importance of the relationship with the clinician, (iii) an opportunity to reflect on past experiences, and (iv) the ability to be able to provide honest responses. Results from this study indicated that young people expected to be asked about their trauma experiences, acknowledged that this was challenging for them but found that this was made easier due to the relationship they had built with the clinician, the timing of the screening and also, possibly, by the written style format of the questionnaires.

CONCLUSIONS

Young people in this study accepted the need for screening for traumatic histories, and expected to be asked about their traumatic experiences, despite the possibility of a short-term increase in distress. The support offered by a trusted clinician, whom the young person had built a relationship with, appeared to be an important component to the willingness and the ability of the young person to complete the questionnaires. This reinforces the fact that screening for trauma in an early psychosis service can be conducted in a way that is safe and acceptable to young people.

What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION

Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers.

METHODS

We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics.

RESULTS

On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider.

CONCLUSIONS

Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Trauma-informed mental health practice during COVID-19: Reflections from a Community of Practice initiative

This article discusses insights arising from a Community of Practice (CoP) initiative within a mental health short stay inpatient unit adjacent to a major Emergency Department to explore how COVID-19 has influenced engagement and support of people in mental distress. The present initiative was designed as a collaboration between the University of South Australia and SA Health. Community of Practice (CoP) is combined with a narrative review of current evidence to explain specific nursing care responses within an operating environment of pandemic-induced fear and uncertainty. Meetings discussed the challenges associated with delivering mental health care for people experiencing mental health distress in the COVID-19 context. Applying trauma-informed principles to mental health care delivery was identified to be of relevance in the context of an ongoing pandemic. Humanizing nursing care and increasing people's sense of predictability and safety contributed to therapeutic engagement and support during COVID-19. Factors discussed to mitigate the effects of safety measures include, for example, nuanced verbal and non-verbal engagement of health workers with people in mental distress when wearing personal protective equipment (PPE). We highlight the need to 'humanise' nursing and openly communicating that both practitioners and people in distress are navigating special circumstances. The CoP participants additionally acknowledged that the experience of moral distress among frontline health workers needs to be addressed in future policy responses to COVID-19. Person-centred and trauma-informed responses at the point of care might help to mitigate the pandemic short- and long-term effects for both service users and frontline health workers.

The 'trauma' of trauma-informed care

OBJECTIVES

As mental health services increasingly position themselves as providing 'trauma-informed care', there is a need for ongoing critical reflection on the challenges that this movement highlights for mental health services, including those related to the concept of trauma itself.

CONCLUSIONS

To become trauma-informed requires opportunities to reflect on what trauma means and consideration of the challenges the concept poses to diagnostically driven systems. Alongside uptake, further debate is required.

Is trauma informed care possible in the current public mental health system?

OBJECTIVES

As mental health services move towards implementing 'Trauma-informed care', there is a need to consider the challenges posed within services and systems. This paper raises some of the challenges associated with integrating TIC into the current public mental health system. .

CONCLUSION

The lack of clarity about expectations of trauma-informed approaches causes difficulties for its integration into services, but the wider political context of mental health services is also of relevance. Transparent and ongoing debate is required about approaches to mental health care, to ensure the system meets the needs of those who require it, while questioning what other purposes it may be serving at social and political levels.

Trauma-informed qualitative research: Some methodological and practical considerations

Mental health nurses who engage in research are likely to undertake research on sensitive topics, related to experiences of illness, care delivery and treatment. With recognition of the high prevalence of trauma in the lives of people who interact with mental health services, it is likely that many research participants will have experienced trauma in their lives and that while this may not be the focus of the research, sensitivity and awareness are required. Reference to 'trauma-informed' approaches in research design and practice is emerging in fields such as trauma-focused research and social sciences; however, it has not yet been applied to nurses. Trauma-informed approaches can build upon existing ethical and methodological frameworks to inform how mental health nurses go about qualitative research and what they need to consider when doing so. This discursive paper explores some of the implications of awareness and sensitivity to trauma for research undertaken by mental health nurses, including practical and methodological considerations. Recommendations include training and structural supports for nurse researchers, collaborative research designs, consideration of the environments where research occurs, awareness of approaches to distress and inclusion of trauma sensitivity within research policies, frameworks and leadership, alongside vigilance to interpersonal approach and the establishment and protection of psychological safety throughout. Continuing to undertake research on topics, and with people, where trauma is present, is essential to ensure ongoing awareness. Many of the existing skills held by mental health nurses can also support research to be undertaken in trauma-informed ways.

Mental Health Service User and Worker Experiences of Psychosocial Support Via Telehealth Through the COVID-19 Pandemic: Qualitative Study

BACKGROUND

During the COVID-19 pandemic, we saw telehealth rapidly become the primary way to receive mental health care. International research has validated many of the benefits and challenges of telehealth known beforehand for specific population groups. However, if telehealth is to assume prominence in future mental health service delivery, greater understanding of its capacity to be used to provide psychosocial support to people with complex and enduring mental health conditions is needed.

OBJECTIVE

We focused on an Australian community-managed provider of psychosocial intervention and support. We aimed to understand service user and worker experiences of psychosocial support via telehealth throughout the COVID-19 pandemic.

METHODS

This study was jointly developed and conducted by people with lived experience of mental ill health or distress, mental health service providers, and university-based researchers. Semistructured interviews were conducted between August and November 2020 and explored participant experiences of receiving or providing psychosocial support via telehealth, including telephone, text, and videoconferencing. Qualitative data were analyzed thematically; quantitative data were collated and analyzed using descriptive statistics.

RESULTS

Service users (n=20) and workers (n=8) completed individual interviews via telephone or videoconferencing platform. Service users received psychosocial support services by telephone (12/20, 60%), by videoconferencing (6/20, 30%), and by both telephone and videoconferencing (2/20, 10%). Of note, 55% (11/20) of service user participants stated a future preference for in-person psychosocial support services, 30% (6/20) preferred to receive a mixture of in-person and telehealth, and 15% (3/20) elected telehealth only. Two meta-themes emerged as integral to worker and service user experience of telehealth during the pandemic: (1) creating safety and comfort and (2) a whole new way of working. The first meta-theme comprises subthemes relating to a sense of safety and comfort while using telehealth; including trusting in the relationship and having and exercising choice and control. The second meta-theme contains subthemes reflecting key challenges and opportunities associated with the shift from in-person psychosocial support to telehealth.

CONCLUSIONS

Overall, our findings highlighted that most service users experienced telehealth positively, but this was dependent on them continuing to get the support they needed in a way that was safe and comfortable. While access difficulties of a subgroup of service users should not be ignored, most service users and workers were able to adapt to telehealth by focusing on maintaining the relationship and using choice and flexibility to maintain service delivery. Although most research participants expressed a preference for a return to in-person psychosocial support or hybrid in-person and telehealth models, there was a general recognition that intentional use of telehealth could contribute to flexible and responsive service delivery. Challenges to telehealth provision of psychosocial support identified in this study are yet to be fully understood.

Navigating the Minefield: Managing Refusal of Medical Care in Older Adults with Chronic Symptoms of Mental Illness

Purpose

The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice.

Case Presentation

Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted.

Conclusion

There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.

What is needed for Trauma Informed Mental Health Services in Australia? Perspectives of clinicians and managers

Trauma Informed Care is an approach to the delivery of mental health care that requires sensitivity to the prevalence and effects of trauma in the lives of people accessing services. While TIC is increasingly emphasized in mental health policy and frameworks in Australia, people working in mental health settings have reportedly struggled to translate the values and principles into their everyday practice. This qualitative study used an experience-based co-design methodology to explore the potential for implementation of Trauma Informed Care into mental health services in Australia. The experiences of consumers, carers, clinicians, and managers were gathered. This paper presents the perspectives of clinicians (n = 64) and senior managers (n = 9) from across three Local Health Districts in New South Wales in Australia. All data were analysed thematically to address the research question: What is needed for Trauma Informed Mental Health Services in Australia? To be trauma-informed, managers required: leadership at all levels, access to resource, relevant and accessible training, support for staff, resolution of wider systems issues, and clarification of the concept and actions of TIC. Clinicians identified that to be trauma-informed they required services to: be aware of staff well-being, support different ways of working, address workplace cultures and provide increased resources. The findings have implications for any service, team or individual seeking to implement TIC within mental health settings.