Positioning mental health nursing practice within a positive health paradigm

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.

The Process of Home-Visiting Nurses Supporting People with Mental Disorders

The number of people with mental disorders (PMD) living in the community is increasing; however, it is unclear how home-visiting nurses (HVNs) supporting them in the community acquire their support skills. This study aimed to reveal the process of how HVNs learn support skills for PMD. Semi-structured interviews were conducted with 14 HVNs supporting PMD living in the community. The grounded theory approach was used for data analysis. As a result, two stages were present: "Explore the personal recovery of PMD" and "Believe in the potential of PMD and accompanying them". The first stage is further divided into two themes: "Overlapping the worlds of PMD and HVNs", and "Easing difficulty in living for PMD". In the first stage, HVNs gained a better understanding of PMD and obtained insight into the support they needed in their daily lives. In the second stage, HVNs became to provide the support that PMD truly needed. HVNs gained a deeper understanding of the reality of PMD through their support. After HVNs found the support PMD required, they sought to provide it, ultimately resulting in finding ways to facilitate the personal recovery of PMD.

Applying Bowen Theory to Psychiatric Assessment and Disposition in the ED

BACKGROUND

A number of variables have been shown to influence whether an individual who experiences an emergency psychiatric assessment is admitted to a psychiatric hospital. This study focused on the theoretical orientation of the assessing clinician as a possibly influential variable. The theoretical orientation being studied was Bowen family systems theory or Bowen theory (Bt). Overall the Bt perspective looks at the family as the primary crucible that generates symptoms but at the same time as the natural unit and the best built-in resource to deal with those symptoms.

AIMS

This study examined whether the theoretical orientation of the nurse psychiatric assessor would affect her inpatient admission rate of patients seen for psychiatric evaluation in an emergency department (ED).

METHOD

A clinician/researcher with extensive experience applying Bt in clinical practice worked in a Crisis Management Service providing psychiatric evaluation and disposition in a busy community hospital ED. Given Bt's emphasis on the system rather than individual pathology, the clinician researcher hypothesized that her psychiatric hospitalization rate would be lower than the other clinical nurse specialists. A retrospective chart review analyzed 1 year of cases from all referrals that might have resulted in psychiatric hospitalizations (n = 1,801).

RESULTS

The clinician/researcher's psychiatric hospitalization rate was significantly lower (p = .004) than the other clinicians.

CONCLUSION

An approach to psychiatric assessment in the ED applied a Bt perspective in a way that significantly reduced psychiatric hospitalizations.

Are current mental health assessment formats consistent with contemporary thinking and practice?

Conducting and documenting a mental health assessment is considered a central activity from a clinical and organizational perspective. In recent years, thinking and practice in mental health service delivery has changed considerably to embrace principles of recovery, trauma-informed care, and strengths-based approaches. The aim of the present study was to determine the degree to which these concepts are reflected in the content of assessment formats across mental health services in Australia and New Zealand. Copies of mental health assessments used in each state and territory in Australia, and three District Health Boards in New Zealand were obtained. Assessment formats were compared for similarities and differences, and to determine whether concepts of recovery, trauma-informed care, and strengths-based approaches were incorporated. The assessment formats analysed (n = 11) contained many traditional features targeted at identifying harms, problems, risks, and pathology. Some attempts to redress this discrepancy were evident. Overall, assessment formats did not adequately voice the individual's perspective or promote a truly comprehensive assessment through an exploration of individual strengths, skills and abilities, past successes, and future hopes. Assessment formats across Australia and New Zealand are not currently aligned with contemporary thinking and practice in mental health care. Given the heavy influence that mental health assessment has on clinical decision making in particular, a reappraisal of the focus and content of formats used is urgently required.

Mental Health Nurses as therapists in a rehabilitation setting: A phenomenological study

Mental Health Nurses have a long tradition of delivering talk-based interventions across a range of clinical settings. Despite this, Mental Health Nurses receive limited recognition of this contribution. This paper presents findings from a study that explored Mental Health Nurses' experience of delivering talk-based therapies in an inpatient rehabilitation setting. This study uses semistructured interviews and a phenomenological approach to explore eight Mental Health Nurses' experience. Themes emerging included that: mental health nursing is a talk-based therapy in its own right, talk-based therapy was part of everyday nursing care on the floor and integrated talk-based therapy enhanced recovery opportunities for consumers. However, a further theme was that there were tensions around providing talk-based therapy conflicted with other roles including unit management and the role of nurses in controlling challenging behaviours. This study found that Mental Health Nurses, in this setting, are offering talk-based therapy to the people they care for. The findings of this study have implications for research: there needs to be a larger study investigating nurses' use of talk-based therapy in inpatient settings. If, as the authors expect that, it is found that mental health nurses are offering these therapies generally in inpatient settings, this has serious implications for postgraduate education in Mental Health Nursing policy in terms of recognition that this is happening and finding ways to support nurses to do this well. There also needs to be further research in the best ways to offer talk-based therapy in these settings.

Introducing solution-focussed brief therapy to mental health nurses across a local health district in Australia

Solution-focussed brief therapy (SFBT) can be applied to effectively address a broad range of mental health-, alcohol-, and substance-related challenges. The compatibility that SFBT has with mental health nursing practice has been widely recognized. The aim of the present mixed-methods study was to introduce and evaluate the utility of SFBT principles, strategies, and techniques to the clinical work of mental health nurses from a local health district in Sydney, Australia. Following a 4-hour introductory SFBT workshop, participants were invited to complete a one-page evaluation and undertake a follow-up individual telephone interview with a research assistant. Participants (n = 65) were positive about the workshop content and recognized the potential benefits of SFBT in clinical practice. Interviewed participants (n = 14) were enthusiastic about SFBT. However, they also identified that using SFBT was challenging, particularly as the approach was considered different to current practices in mental health services. A lack of confidence with incorporating SFBT in their clinical work was also acknowledged, and participants expressed interest in additional training, including more time to practise SFBT strategies and techniques. Widespread training for mental health nurses in SFBT is indicated, including opportunities for supervision and to observe SFBT being employed by experienced clinicians.

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.

Being Accountable or Filling in Forms: Managers and Clinicians' Views About Communicating Risk

PURPOSE

Assessment, documentation, and prevention of risk are central to mental health services. However, there is a paucity of research examining how risk is perceived by key stakeholders including managers and clinicians.

DESIGN AND METHODS

Qualitative, exploratory design. In-depth interviews were held with 22 senior managers and 21 clinicians.

FINDINGS

Communicating risk was a major theme to emerge. For managers, accountability was a primary consideration in communicating risk and therefore influential over nursing practice. Clinicians were more likely to view the organizational processes of communicating risk as a bureaucratic exercise.

PRACTICE IMPLICATIONS

The significant difference between managers and clinicians is problematic for achieving consumer-focused mental health service delivery, a more critical approach to risk is essential in preserving the therapeutic relationship.

Perception of risk for older people living with a mental illness: Balancing uncertainty

Risk is commonly defined as a negative threat which needs to be controlled and mitigated; as a concept, it takes high priority in contemporary mental health services. Health-care organizations and clinicians are now required to use levels of risk as a benchmark for clinical decision-making. However, perceptions of risk change according to the lens through which it is viewed. A qualitative, exploratory research study was undertaken in an aged persons' mental health programme in Victoria, Australia, to explore the notion of risk from the multiple perspectives of service providers and consumers. Data were obtained through in-depth interviews, and analysis was based on the framework of Ritchie and Spencer. Balancing uncertainty emerged as a major theme, and comprised two subthemes: (i) complexity of risk from the perspective of providers of services; and (ii) complexity of safety from the perspectives of recipients of services. These differences emphasize a significant disjuncture between perceptions of risk and the potential for the individual needs and concerns of consumers to be subsumed under broader organizational issues. The uncertainty this tension highlights suggests the need to reconceptualize risk, incorporating the views and experiences of all stakeholders, particularly consumers and carers, to enhance recovery-oriented services and facilitate consumer participation within mental health services.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

The language of risk: common understanding or diverse perspectives?

Risk as a concept now takes high priority in contemporary mental health services, with increasing pressure on mental health services to develop risk assessment and management practices. This focus on risk has been criticised for its over-reliance on measurement and management at the expense of therapeutic care and is perpetuated by the language of risk which reinforces power differentials and limits capacity for consumers and carers to influence discussions and debates. Furthermore, to date, most work in this area reflects adult settings with limited consideration of the unique needs of older people and the impact of risk assessment on the care they receive. A qualitative, exploratory approach was undertaken using individual interviews and focus groups to enhance understanding of how risk is conceptualised within an older persons' setting. Managers, clinicians, consumers, and carers from a large metropolitan service participated (n = 57). The language of risk was a major theme emerging from this work. This language, so familiar to providers of services, was not familiar to consumers and carers. A reframing of risk is necessary to reflect consumers' and carers' experiences and understandings. This approach will be essential in promoting consumer and carer participation within recovery-based services, reflecting significant goals of government policy.

Solution-focused approach therapy for mental health nursing students

Solution-focused therapy is a model of therapy that builds on the client's strengths, is future-focused and can be generally offered as a brief intervention. It can be used across multiple clinical settings and is not limited to being useful for clients accessing mental health services. Learning the underlying principles and developing a foundation level of skill in the approach was found to be achievable in an undergraduate nursing course, with students reporting an increase in their knowledge of the model and confidence in basic therapeutic skills in just one day of training. In this paper, we introduce the solution-focused approach in relation to nursing practice. We describe the template used for the training day offered to undergraduate mental health nurses. Students reported that this method of learning a therapeutic approach was helpful and increased both their knowledge and skill base.