Implications of evidence-based practice for mental health nursing

A Mismatch of Paradigms Disrupts the Introduction of Psycho-Educative Interventions for Families of Persons with SMI: An Interview Study with Staff from Community Services

Treatment and support of people diagnosed with severe mental illness in Sweden takes place in out-patient psychiatric services or municipality services. Most of the responsibility for support in daily life are provided by the close family. One crucial matter is how to support these families. This research project aimed to investigate the Swedish construction with shared responsibility between county psychiatric care and municipality social care for consumers with severe mental illness affects actions in municipalities in relation to family support. Ten representatives from five municipality settings were interviewed. Five semi-structured interviews were analysed using a thematic analysis. The following themes emerged; One overarching theme, "a mismatch of paradigms", and sub-themes: (a) "accentuating differences", (b) "doubts about including the entire family in the same session" and (c) "lack of a uniform family support policy". We conclude that a shared mandate needs a dialogue between psychiatric and municipality services concerning this mismatch.

Evidence-Based Practice in Forensic Mental Health Nursing: A Critical Review

METHOD

Literature searches of databases, particularly CINAHL, using key phrases were undertaken.

RESULTS

Some authors argue that there is a lack of evidence in forensic mental health (FMH) nursing, with few randomized controlled trials and other methods providing definitive, generalizable evidence. However, literature searches revealed randomized controlled trials of relevance to FMH nursing, many qualitative studies by FMH nurses, and arguments for clinical experience and knowledge of service users, and the latter's views, as sources of evidence.

DISCUSSION AND IMPLICATIONS FOR NURSING PRACTICE

Research findings can be applied to practice, both directly and indirectly. Examples are given of ways that evidence can be used to inform FMH nursing interventions related to therapeutic ward environments, including communication, therapeutic relationships, preventing retraumatization, and enabling physical health. The complex nature of "evidence" is considered in relation to risk assessment and management.

CONCLUSIONS FOR NURSING PRACTICE

FMH nursing can be based on a wide range of sources of evidence. The types of evidence used in practice depend on individual service users' needs and views. In evaluating evidence, it is necessary to be aware of its complex, diverse nature. A distinction can be made between definitive, widely generalizable research findings and evidence with limited generalizability, requiring FMH nurses' judgments about whether it is applicable to their own area of practice. Recommendations for related education and research are made.

Sources of Knowledge and Barriers of Implementing Evidence-Based Practice Among Mental Health Nurses in Saudi Arabia

PURPOSES

The purposes of this study were to identify the sources of knowledge for nursing practices and to identify the barriers of using "evidence-based practice" (EBP).

DESIGN AND METHODS

Descriptive cross-sectional design was used to collect data from 164 Saudi mental health nurses by completing the Development of Evidence-Based Practice Questionnaire.

FINDINGS

The most frequently used sources of knowledge were relied on social interactions and the nurses' own experiences, while the least frequently used sources were external sources of knowledge and research evidences. Insufficient time to find research reports, difficulty in understanding research reports, and insufficient resources for evidences were the barriers of using EBP.

PRACTICE IMPLICATIONS

The organizations should encourage using EBP by providing adequate time, resources, knowledge, and skills for mental health nurses through conducting workshops and mentoring.

Reconnecting with oneself while struggling between life and death: The phenomenon of recovery as experienced by persons at risk of suicide

The body of knowledge regarding health and recovery as experienced by patients at risk of suicide is limited. More research is needed into the meaning of recovery and what strengthens the desire to live. The aim of this study was to describe the phenomenon of recovery in a context of nursing care as experienced by persons at risk of suicide. In line with a reflective lifeworld research approach, 14 patients from a psychiatric clinic in Sweden participated in phenomenon-oriented interviews. Data were analyzed to describe the essence of the phenomenon. The results reveal that the phenomenon of recovery means 'reconnecting with oneself while struggling between life and death'. Three meaning constituents emerged: being in an expressive space and giving voice to oneself, regaining dignity through nurturing connectedness, and finding a balance in the tension between life and death. In conclusion, the meaning of recovery is to experience the ability to manage one's own life. Professional caregivers need to acknowledge patients' lifeworlds, in a way that enable patients to experience themselves as capable of managing their own lives. Professional caregivers should also facilitate the involvement of supportive relatives.

Handover of patient information from the crisis assessment and treatment team to the inpatient psychiatric unit

Handover, or the communication of patient information between clinicians, is a fundamental component of health care. Psychiatric settings are dynamic environments relying on timely and accurate communication to plan care and manage risk. Crisis assessment and treatment teams are the primary interface between community and mental health services in many Australian and international health services, facilitating access to assessment, treatment, and admission to hospital. No previous research has investigated the handover between crisis assessment and treatment teams and inpatient psychiatric units, despite the importance of handover to care planning. The aim of the present study was to identify the nature and types of information transferred during these handovers, and to explore how these guides initial care planning. An observational, exploratory study design was used. A 20-item handover observation tool was used to observe 19 occasions of handover. A prospective audit was undertaken on clinical documentation arising from the admission. Clinical information, including psychiatric history and mental state, were handed over consistently; however, information about consumer preferences was reported less consistently. The present study identified a lack of attention to consumer preferences at handover, despite the current focus on recovery-oriented models for mental health care, and the centrality of respecting consumer preferences within the recovery paradigm.

Perceptions of national guidelines and their (non) implementation in mental healthcare: a deductive and inductive content analysis

BACKGROUND

National guidelines are being produced at an increasing rate, and politicians and managers are expected to promote these guidelines and their implementation in clinical work. However, research seldom deals with how decision-makers can perceive these guidelines or their challenges in a cultural context. Therefore, the aim of this study was twofold: to investigate how well Promoting Action on Research Implementation in Health Services (PARIHS) reflected the empirical reality of mental healthcare and to gain an extended understanding of the perceptions of decision-makers operating within this context, in regard to the implementation of evidence-based guidelines.

METHODS

The study took place in the southeast of Sweden and employed a qualitative design. The data were collected through 23 interviews with politicians and managers working either in the county council or in the municipalities. The transcribed text was analysed iteratively and in two distinct phases, first deductively and second inductively by means of qualitative content analysis.

RESULTS

Our deductive analysis showed that the text strongly reflected two out of three categorisation matrices, i.e. evidence and context representing the PARIHS framework. However, the key element of facilitation was poorly mirrored in the text. Results from the inductive analysis can be seen in light of the main category sitting on the fence; thus, the informants' perceptions reflected ambivalence and contradiction. This was illustrated by conflicting views and differences in culture and ideology, a feeling of security in tradition, a certain amount of resistance to change and a lack of role clarity and clear directions. Together, our two analyses provide a rich description of an organisational culture that is highly unlikely to facilitate the implementation of the national guidelines, together with a distrust of the source behind such guidelines, which stands in stark contrast to the high confidence in the knowledge of experienced people in authority within the organisational context.

CONCLUSIONS

Our findings have highlighted that, regardless of by whom guidelines are released, they are not likely to be utilised or implemented if those who are responsible for implementing them do not trust the source. This aspect (i.e. contextual trust) is not covered by PARIHS.

Perceptions of national guidelines and their (non) implementation in mental healthcare: a deductive and inductive content analysis

BACKGROUND

National guidelines are being produced at an increasing rate, and politicians and managers are expected to promote these guidelines and their implementation in clinical work. However, research seldom deals with how decision-makers can perceive these guidelines or their challenges in a cultural context. Therefore, the aim of this study was twofold: to investigate how well Promoting Action on Research Implementation in Health Services (PARIHS) reflected the empirical reality of mental healthcare and to gain an extended understanding of the perceptions of decision-makers operating within this context, in regard to the implementation of evidence-based guidelines.

METHODS

The study took place in the southeast of Sweden and employed a qualitative design. The data were collected through 23 interviews with politicians and managers working either in the county council or in the municipalities. The transcribed text was analysed iteratively and in two distinct phases, first deductively and second inductively by means of qualitative content analysis.

RESULTS

Our deductive analysis showed that the text strongly reflected two out of three categorisation matrices, i.e. evidence and context representing the PARIHS framework. However, the key element of facilitation was poorly mirrored in the text. Results from the inductive analysis can be seen in light of the main category sitting on the fence; thus, the informants' perceptions reflected ambivalence and contradiction. This was illustrated by conflicting views and differences in culture and ideology, a feeling of security in tradition, a certain amount of resistance to change and a lack of role clarity and clear directions. Together, our two analyses provide a rich description of an organisational culture that is highly unlikely to facilitate the implementation of the national guidelines, together with a distrust of the source behind such guidelines, which stands in stark contrast to the high confidence in the knowledge of experienced people in authority within the organisational context.

CONCLUSIONS

Our findings have highlighted that, regardless of by whom guidelines are released, they are not likely to be utilised or implemented if those who are responsible for implementing them do not trust the source. This aspect (i.e. contextual trust) is not covered by PARIHS.

'How do we know if this is the best?' Mental health-care professionals' views on national guidelines for psychosocial interventions

National guidelines are released regularly, and professionals are expected to adopt and implement them. However, studies dealing with mental health-care professionals' views about guidelines are sparse. The aim of the present study was to highlight mental health-care staff's views on the Swedish national guidelines for 'psychosocial interventions for schizophrenia or schizophrenia-type symptoms' and their implementation. The study took place in the southeast parts of Sweden, and data were collected through five group interviews consisting of 16 professionals working either in the county council or in the municipalities. The transcribed text was analysed by content analysis, revealing two categories. The first category 'a challenge to the practice of care as known' reflected that the release of guidelines could be perceived as a challenge to prevailing care and culture. The second category 'anticipating change to come from above' mirrored views on how staff expected the implementation process to flow from top to bottom. To facilitate working in accordance with guidelines, we suggest that future guidelines should be accompanied by an implementation plan, where the educational needs of frontline staff are taken into account. There is also a need for policy makers and managers to assume responsibility in supporting the implementation of evidence-based practice.

Learning essentials: what graduates of mental health nursing programmes need to know from an industry perspective

AIMS AND OBJECTIVES

To explore the perspectives of nursing directors in mental health in Queensland, Australia, regarding the skills and attributes of graduates of comprehensive nursing programme to provide an industry perspective and thus augment knowledge from theoretical and professional dimensions.

BACKGROUND

There is a worldwide shortage of appropriately qualified nurses with the knowledge, skills and attitudes to work effectively in mental health services. Within Australia, this has been well documented since the introduction of comprehensive nursing education. The underrepresentation of mental health content in undergraduate curricula has been identified as the primary reason for nursing graduates not being adequately prepared for practice in this field. To date, this issue has primarily been addressed from the perspective of university academics, with the voice of industry relatively silent in the published literature.

DESIGN

Qualitative exploratory.

METHOD

In-depth telephone interviews with Director of Nursing (Mental Health) in Queensland, Australia.

RESULTS

The concerns of participants were expressed in six main themes: (1) foundational knowledge of mental health and disorders, (2) recovery-oriented skills, (3) physical as well as mental health skills, (4) therapeutic strategies, (5) resilience and self-development and (6) advanced knowledge and skills.

CONCLUSIONS

The education of comprehensive nursing education needs to be reviewed as a matter of priority to ensure graduates with the attributes required to provide high-quality care for consumers of mental health services.

RELEVANCE TO CLINICAL PRACTICE

A skilled and knowledgeable workforce is an essential component of high-quality mental health services. Research highlighting the current deficits and issues is therefore of the highest priority.

Barriers to evidence-based practice utilization in psychiatric/mental health nursing

Many psychiatric/mental health nursing (PMHN) practices have been affected by old traditions and haphazard trial and error instead of by established scientific evidence. The purpose of this article is to explore and analyze the barriers surrounding evidence-based practice (EBP) in PMHN. I identify some strategies to overcome these barriers in an attempt to incorporate EBP within the framework of PMHN services. Barriers explain the lack of EBP in today's PMHN environment. The barriers identified in this research are: the nature of the evidence, the contribution of the psychiatric nursing researchers to EBP, the personal characteristics of psychiatric nurses, and organizational factors. While the barriers to EBP for PMHN practice are clearly apparent, the challenge, now, is to build up creative strategies through which psychiatric nurses are better able to provide EBP care as part of their everyday performance. Adaptation of a more dynamic form of EBP, increasing the number of PMHN researchers, conducting clinical research projects, choosing suitable journals for publication, training the psychiatric nurses about computer skills, integrating the EBP principles into nursing curricula, developing journal clubs, and offering organizational facilitators are essential prerequisites for the achievement of EBP in the PMHN field. It is no longer justifiable for psychiatric nurses to be deficient in knowledge and skill since the advantages of EBP for patients are well-documented.

Identifying mental health nursing research priorities: A Delphi study

Abstract Engaging in research and using evidence based practice are essential for mental health nurses to provide quality nursing care to consumers and families. This paper reports on a Delphi study that identified the top ten mental health nursing research priorities at one area health service in Australia servicing a population of 840,000 people. Initially 390 research questions were identified by nurses and these were then reduced to 56 broader questions. Finally, the top ten questions were ranked in order of importance. The priority questions were clinically and professionally focused and included research into the delivery and organisation of mental health services and the need to design and evaluate new practice paradigms for nurses in the primary care setting. The mental health knowledge and skill set of graduates from Australian comprehensive nursing programs along with improved recruitment and retention of graduates in mental health were also identified priority areas for research.

The experience of weight gain as a result of taking second-generation antipsychotic medications: the mental health consumer perspective

This interpretive qualitative study aimed to describe and construct the meaning of the experience of living with the weight gain associated with second-generation antipsychotics. A qualitative study that incorporated the tenets of phenomenology and utilized in-depth interviews was conducted with eight mental health consumers. Thematic analysis resulted in three themes: Grappling with the weight; Living with the consequences of being overweight; and Experiencing negative emotions about the weight gain. The findings indicate that consumers struggle to manage the insatiable appetite and the related weight gain associated with second-generation antipsychotic medication, as well as the numerous associated physical and emotional issues. Adherence with prescribed second-generation antipsychotic medication was also affected and a number of the participants indicated they had ceased or considered ceasing their medication because of the weight gain associated with the drugs.

Consumer's perceptions of Recovery-oriented mental health services: an Australian case-study analysis

Recovery approaches to health care now feature in the mental health policies of many Western countries. There are, however, continuing challenges to the operationalization of these approaches. This study aimed to identify the nature of these challenges for a public mental health service organization located in a major urban center in southeastern Australia, where Recovery-oriented services have been implemented; and to develop recommendations to address these challenges. These aims were achieved by asking mental health consumers about their experiences of the implementation of Recovery-oriented services. Research participants described an uncertainty in health professionals and consumers alike about how to practice within a Recovery model, with many health professionals taking a "hands off" approach in the name of Recovery, rather than working in partnership with consumers and other stakeholders, including the community managed organizations. Solutions to these challenges included more targeted, practice-focused education for consumers and health professionals, with this education provided by consumer representatives. Insights derived from this research add to the growing body of evidence related to the implementation of Recovery-oriented services in Western countries.

Recovery of evidence-based practice

Consumer recovery is now enshrined in the national mental health policy of many countries. If this construct, which stems from the consumer/user/survivor movement, is truly to be the official and formal goal of mental health services, then it must be the yardstick against which evidence-based practice (EBP) is judged. From a consumer-recovery perspective, this paper re-examines aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence associated with EBP, those previously having been identified as deficient and in need of expansion. One of the significant differences between previous investigations and the present study is that the work, writing, perspectives, and advocacy of the consumer movement has developed to such a degree that we now have a much more extensive body of material upon which to critique EBP and inform and support the expansion of EBP. Our examination reinforces previous findings and the ongoing need for expansion. The consumer recovery-focused direction, resources, frameworks, and approaches identified through the present paper should be used to expand the aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence. This expansion will ultimately enable services to practice in a manner consistent with the key characteristics of supporting personal recovery.

Psychiatric elopement: using evidence to examine causative factors and preventative measures

BACKGROUND

Elopement is a problem in the inpatient mental health community. Elopement can have serious and long term effects for the patients and staff.

OBJECTIVE

The purposes of this paper are to present a review of the literature regarding elopement and to provide recommendation for practice.

DESIGN

Using several databases, a search of the existing literature was conducted.

RESULTS

Elopement occurs due to a number of factors, including: psychosocial issues, staff-patient interaction, the patient's attitude toward hospitalization, and their mental illness.

CONCLUSION

It is important to understand why patients seek to elope from treatment facilities to prevent further occurrences.

Does individual placement and support really 'reflect client goals'?

Individual placement and support (IPS) is considered the only evidence-based practice available for providing vocational support within secondary mental health services. Clients are supported into and during competitive employment, with proponents claiming IPS 'reflects client goals' because most service users want to work. The idea that work improves mental health is also involved in promoting IPS in the U.K. This paper examines the evidential basis for these claims in policy documents and cited research. It additionally draws upon qualitative research in representing the value, meaning and challenges of working described by service users, while briefly considering the U.K. socio-economic context for IPS implementation. Statistical claims that most unemployed service users want to work are found misleadingly applied to IPS because only a minority say they want competitive employment. Discussion centres on the power interests such statistics serve and their role in underpinning the relevance of IPS randomized control trials. Assertions that work improves mental health are found confusing as a result of use of a dual continua model of mental illness and mental health. The internalized moral basis for work acting as a seemingly healthy 'normalization' experience is suggested as paradoxically feeding self-stigma in those who feel they cannot work.

Investigating the evidence for the effectiveness of risk assessment in mental health care

Risk assessment pervades mental health care policy, practice, and legislation. This paper aims to establish the research evidence for the effectiveness of a risk assessment approach in mental health. A search was conducted of the professional literature on risk assessment in mental health, specifically seeking any research on the effectiveness of risk assessment in reducing risk of harm to self or others. The search found limited research on the effectiveness of risk assessment. "Structured professional judgment" possibly reduces aggression risk but there is no evidence that risk assessment is effective in relation to self-harm or suicide reduction. The implications for practice are discussed and alternatives to a risk assessment approach are considered.

Placing physical activity in mental health care: a leadership role for mental health nurses

The wide-ranging benefits of physical activity for consumers with mental illness are acknowledged within the mental health nursing field; however, this is not commonly translated to practice. The primary aim of this paper is to argue that mental health nurses are well positioned to, and should, provide leadership in promoting physical activity to improve the quality of care for people with mental illness. Topics addressed in this paper include the relationship between physical activity and both physical and mental health, the views and experiences of consumers with physical activity, the efficacy of physical activity interventions, the attitudes of nurses to physical activity as a component of care, barriers to a physical activity focus in care for mental illness, and the role of mental health nurses in promoting physical activity. There is a clear and important relationship between physical activity and mental health. Mental health nurses are well positioned to encourage and assist consumers to engage in physical activity, although they might lack the educational preparation to perform this role effectively.

A UK validation of the Stages of Recovery Instrument

OBJECTIVE

There is considerable interest in the concept of recovery from psychosis. Consumers describe recovery as a process as opposed to a clinical outcome. However, measures of recovery have an important role in the development of recovery-based mental health services. This study sought to investigate the validity and reliability of the Stages of Recovery Instrument (STORI) (Andresen et al., 2006). This is an Australian instrument chosen as a promising measure of recovery developed from the perspectives of consumer accounts.

METHOD

A questionnaire design was used to investigate the following aspects of validity: face validity and feasibility; concurrent validity; construct validity; and test-retest reliability. Fifty (50) people from the caseloads of three specialist mental health teams in a London borough completed the STORI, the Recovery Assessment Scale (RAS) (Corrigan et al., 1999) and a feedback questionnaire. Twenty two (22) people completed the STORI a second time for the purposes of test-retest reliability exploration.

RESULTS

Participants' responses to the feedback questionnaire were mainly positive. This was seen as evidence of face validity and feasibility. Correlations between the STORI and the RAS provided evidence of concurrent validity. Cluster analysis revealed that the STORI items formed three clusters rather than five. Strong correlations between the first and second STORI administrations provided initial evidence for the test-retest reliability.

CONCLUSIONS

The STORI can be used to measure recovery concepts in the UK. However, it does not measure the five-stage model on which it was based. A three-stage model of recovery might best form the basis of future recovery research.

Developing partnerships in mental health to bridge the research-practitioner gap

PURPOSE

An overview of approaches used in contemporary mental health research to consider when coordinating research agendas is presented. Connections between the research-practice gap and evidence-based practice are explored. Collaboration, as a key concept and practice, is investigated particularly in relation to community and consumer participation in mental health research.

CONCLUSIONS

Non-commensurate belief systems, inadequate infrastructure, and institutional tendencies maintain the status quo and constitute significant impediments to widespread planned and integrated research programs.

PRACTICE IMPLICATIONS

Communication and trust building between researchers and practitioners is central to developing effective collaborations that can deliver more effective health care.

The impact of mental health nursing education on undergraduate nursing students' attitudes to consumer participation

Consumer participation in all aspects of mental health service delivery, including the education of mental health professionals, is now a policy expectation in Australia. Whether education programs introducing nurses to mental health nursing lead to more favourable attitudes towards consumer participation is yet to be examined in pre-registration nursing programs in Australia. The current evaluation examined changes in scores for the Consumer Participation Survey for undergraduate nursing students (n = 68) in an Australian University. Data were analysed, using repeated measures t-test, to compare the pre- and post-test scores. There was a significant improvement in views on consumers participating as staff members. There were no statistically significant changes in attitudes towards consumer capacity and consumer involvement in care processes. Consumer participation in mental health care is now clearly articulated in Australian Government policy. For this to be successfully implemented a more comprehensive understanding of the ability of education to influence attitudes is required.

A review of consumer-provided services on assertive community treatment and intensive case management teams: implications for future research and practice

BACKGROUND

Assertive community treatment (ACT) is an evidence-based practice that provides intensive, in vivo services for adults with severe mental illness. Some ACT and intensive case management teams have integrated consumers as team members with varying results.

METHODS

The authors reviewed the literature examining the outcomes of having consumer providers on case management teams, with attention devoted to randomized controlled trials (RCTs).

RESULTS

Sixteen published studies were identified, including eight RCTs. Findings were mixed, with evidence supporting consumer-provided services for improving engagement and limited support for reduced hospitalizations. However, evidence was lacking for other outcomes areas such as symptom reduction or improved quality of life.

CONCLUSION

Including a consumer provider on an ACT team could enhance the outreach mechanisms of ACT, using a more recovery-focused approach to bring consumers into services and help engage them over time. More rigorous research is needed to further evaluate integrating consumer providers on teams.

Mental illness and well-being: the central importance of positive psychology and recovery approaches

BACKGROUND

A new evidence base is emerging, which focuses on well-being. This makes it possible for health services to orientate around promoting well-being as well as treating illness, and so to make a reality of the long-standing rhetoric that health is more than the absence of illness. The aim of this paper is to support the re-orientation of health services around promoting well-being. Mental health services are used as an example to illustrate the new knowledge skills which will be needed by health professionals.

DISCUSSION

New forms of evidence give a triangulated understanding about the promotion of well-being in mental health services. The academic discipline of positive psychology is developing evidence-based interventions to improve well-being. This complements the results emerging from synthesising narratives about recovery from mental illness, which provide ecologically valid insights into the processes by which people experiencing mental illness can develop a purposeful and meaningful life. The implications for health professionals are explored. In relation to working with individuals, more emphasis on the person's own goals and strengths will be needed, with integration of interventions which promote well-being into routine clinical practice. In addition, a more societally-focussed role for professionals is envisaged, in which a central part of the job is to influence local and national policies and practices that impact on well-being.

SUMMARY

If health services are to give primacy to increasing well-being, rather than to treating illness, then health workers need new approaches to working with individuals. For mental health services, this will involve the incorporation of emerging knowledge from recovery and from positive psychology into education and training for all mental health professionals, and changes to some long-established working practices.

Redressing the balance in mental health nursing education: arguments for a values-based approach

Evidence-based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self-examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.