Storytelling; safeguarding; treatment; and responsibility; attributes of recovery in psychiatric intensive care units

Background and aim In recent years policy in Australia has endorsed recovery-oriented mental health services underpinned by the needs, rights and values of people with lived experience of mental illness. This paper critically reviews the idea of recovery understood by nurses at the frontline of services for people experiencing acute psychiatric distress. Method Data gathered from focus groups held with nurses from two hospitals were used to ascertain their use of terminology, understanding of attributes and current practices that support recovery for people experiencing acute psychiatric distress. A review of literature further examined current nurse based evidence and nurse knowledge of recovery approaches specific to psychiatric intensive care settings. Results Four defining attributes of recovery based on nurses’ perspectives are shared to identify and describe strategies that may help underpin recovery specific to psychiatric intensive care settings. Conclusion The four attributes described in this paper provide a pragmatic framework with which nurses can reinforce their clinical decision-making and negotiate the dynamic and often incongruous challenges they experience to embed recovery-oriented culture in acute psychiatric settings.

Validity of the geriatric depression scale and the collateral source version of the geriatric depression scale in nursing homes

Background Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting. Methods Eighty-eight residents from 14 nursing homes were assessed for depression using the GDS and the CS-GDS, and validated against clinician diagnosed depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders (SCID) for residents without dementia and the Provisional Diagnostic Criteria for Depression in Alzheimer Disease (PDCdAD) for those with dementia. The screening performances of five versions of the GDS (30-, 15-, 10-, 8-, and 4-item) and two versions of the CS-GDS (30- and 15-item) were analyzed using receiver operating characteristic (ROC) curves. Results Among residents without dementia, both the self-rated (AUC = 0.75–0.79) and proxy-rated (AUC = 0.67) GDS variations performed significantly better than chance in screening for depression. However, neither instrument adequately identified depression among residents with dementia (AUC between 0.57 and 0.70). Among the GDS variations, the 4- and 8-item scales had the highest AUC and the optimal cut-offs were >0 and >3, respectively. Conclusions The validity of the GDS in detecting depression requires a certain level of cognitive functioning. While the CS-GDS is designed to remedy this issue by using an informant, it did not have adequate validity in detecting depression among residents with dementia. Further research is needed on informant selection and other factors that can potentially influence the validity of proxy-based measures in the nursing home setting.

Re-focusing risk assessment in forensic mental health nursing.

Editorial in the Journal of Psychiatric and Mental Health Nursing, 2015, 22(7)

The impact of organisational factors and government policy on psychiatric nurses family focused practice with parents who have mental illness, their dependent children and families in Ireland

Government policy and organizational factors influence family focused practice in adult mental health services. However, how these aspects shape psychiatric nurses’ practice with parents who have mental illness, their dependent children and families is less well understood. Drawing on the findings of a qualitative study, this article explores the way in which Irish policy and organizational factors might influence psychiatric nurses’ family focused practice, and whether (and how) family focused practice might be further promoted. A purposive sample of 14 psychiatric nurses from eight mental health services completed semi-structured interviews in 2013. The analysis was inductive and presented as thematic networks. Both groups described how policies and organizational culture enabled and/or hindered family focused practice, with differences between community and acute participants seen. The need to develop national and international policies along with practices to embed information and support regarding parenting into ongoing care is implicated in this study.

Cognition and psychopathology in nonagenarians and centenarians living in geriatric nursing homes in Switzerland: a focus on anosognosia.

BACKGROUND: The number of nonagenarians and centenarians is rising dramatically, and many of them live in nursing homes. Very little is known about psychiatric symptoms and cognitive abilities other than memory in this population. This exploratory study focuses on anosognosia and its relationship with common psychiatric and cognitive symptoms. METHODS: Fifty-eight subjects aged 90 years or older were recruited from geriatric nursing homes and divided into five groups according to Mini-Mental State Examination scores. Assessment included the five-word test, executive clock-drawing task, lexical and categorical fluencies, Anosognosia Questionnaire-Dementia, Neuropsychiatric Inventory, and Charlson Comorbidity Index. RESULTS: Subjects had moderate cognitive impairment, with mean ± SD Mini-Mental State Examination being 15.41 ± 7.04. Anosognosia increased with cognitive impairment and was associated with all cognitive domains, as well as with apathy and agitation. Subjects with mild global cognitive decline seemed less anosognosic than subjects with the least or no impairment. Neither anosognosia nor psychopathological features were related to physical conditions. CONCLUSIONS: Anosognosia in oldest-old nursing home residents was mostly mild. It was associated with both cognitive and psychopathological changes, but whether anosognosia is causal to the observed psychopathological features requires further investigation.

Delirium upon admission to Swiss nursing homes: a cross-sectional study.

QUESTIONS UNDER STUDY: We wished to investigate the prevalence of delirium in patients upon admission to nursing homes and whether or not the previous place of residence predicts delirium. METHODS: The Resident Assessment Instrument Minimum Data Set (RAI-MDS) and the Nursing Home Confusion Assessment Method (NHCAM) were used to determine whether the previous place of residence (community, nursing home, acute care, psychiatric, rehabilitation hospital) predicted the prevalence of sub-syndromal or full delirium in nursing home residents in three Swiss cantons (n = 11745). RESULTS: 39.7% had sub-syndromal and 6.5% had full delirium. Lower cognitive performance and increased depressive symptoms were significant predictors of higher NHCAM values independent of previous residence. Age, civil status, continence, newly introduced drugs, and basic activities of daily living were predictors in some resident groups. The variance of NHCAM scores explained varied between 25.1% and 32.3% depending on previous residence. CONCLUSIONS: Sub-syndromal and full delirium are common upon nursing home admission. Increased dependence and depression are consistently associated with higher NHCAM scores. Patients from psychiatric settings have an increased risk of delirium. Although factors associated with delirium depend on a patient's previous residence, all patients must be carefully screened for sub-syndromal and full delirium.

Delirium upon admission to Swiss nursing homes

QUESTIONS UNDER STUDY: We wished to investigate the prevalence of delirium in patients upon admission to nursing homes and whether or not the previous place of residence predicts delirium. METHODS: The Resident Assessment Instrument Minimum Data Set (RAI-MDS) and the Nursing Home Confusion Assessment Method (NHCAM) were used to determine whether the previous place of residence (community, nursing home, acute care, psychiatric, rehabilitation hospital) predicted the prevalence of sub-syndromal or full delirium in nursing home residents in three Swiss cantons (n = 11745). RESULTS: 39.7% had sub-syndromal and 6.5% had full delirium. Lower cognitive performance and increased depressive symptoms were significant predictors of higher NHCAM values independent of previous residence. Age, civil status, continence, newly introduced drugs, and basic activities of daily living were predictors in some resident groups. The variance of NHCAM scores explained varied between 25.1% and 32.3% depending on previous residence. CONCLUSIONS: Sub-syndromal and full delirium are common upon nursing home admission. Increased dependence and depression are consistently associated with higher NHCAM scores. Patients from psychiatric settings have an increased risk of delirium. Although factors associated with delirium depend on a patient's previous residence, all patients must be carefully screened for sub-syndromal and full delirium.

Assessing Nursing Assistants' Knowledge of Behavioral Approaches to Mental Health Problems

Nurse's aides are the primary caregivers in nursing homes, a major receiving site for elders with behavioral and psychiatric problems. We describe the development, psychometric properties, and utility of a brief instrument designed to assess aides' knowledge of three specific mental health problems (depression, agitation, and disorientation) and behavioral approaches to them. The instrument was administered to 191 nurse's aides and 21 clinicians with training in behavioral management and experience with older residents. The nurse's aides averaged 11 of 17 correct answers, and the clinicians averaged 15 of 17 correct answers. Implications for staff training and consultation activities in nursing homes are discussed.

The Relationship of Antipsychotic Drug Use, Resident Behavior, and Diagnoses Among Nursing Home Residents

Nursing homes have been criticized for frequent use and possible misuse of psycho-active agents. These issues are of clinical concern and policy relevance, especially since the passage of the Omnibus Budget Reconciliation Act (OBRA) of 1987. Using a sample of 419 residents, the authors examined the relationships among antipsychotic drug (AP) use, behavior, and mental health diagnoses. Only 23.2% of the residents were administered APs on a routine and/or "as-needed" basis. Based on the Multidimensional Observation Scale for Elderly Subjects (MOSES) ratings, AP users were more irritable, disoriented, and withdrawn than were nonusers. Also, AP users demonstrated agitated behaviors more frequently. Notably, AP users and nonusers differed significantly in terms of documented mental health diagnoses. Among AP users, 70.1% had documented dementia, 8.3% were psychotic or had other psychiatric disorders, and 21.6% had no mental health diagnoses. In contrast, the majority of nonusers had no mental health disorders. Logistic regression revealed that diagnostic factors, frequency of agitation, level of withdrawal, and marital status were significant predictors of AP use.

Psychiatrists' and Psychiatric APRNs' Views of the Adolescent Mental Health Nurse's Role In the Inpatient Setting

Current perceptions about nurses’ roles and responsibilities are examined in this study, specifically relating to adolescent inpatient MHNs. Psychiatrists and psychiatric advanced practice registered nurses (APRNs), who work with MHNs and have also published scholarly psychiatric articles, were contacted to request their participation in an anonymous survey hosted by SurveyMonkey.com. This research was conducted to examine the stereotypes that exist against nurses within the health care profession itself, as compared to the pre-existing stereotypes displayed by the media’s view of nurses. Due to investigator time constraints, only six subjects participated in the study. Analysis of survey responses revealed four overarching themes. First, MHNs are a critical component of the health care team, emerging as rigorous, independent leaders, although still classified as female and sociable. Second, MHNs complete a wide range of daily activities, many of which go unnoticed by observers, often resulting in mixed feelings regarding whether MHNs are given the respect and recognition deserved. Third, MHNs treat each patient as a person with unique thoughts, feelings, and physical make-up. Fourth, MHNs act as a coordinator of care between various health professionals to provide the patient with a holistic approach to healing.

Effects of patient-focused care on seclusion in a psychiatric intensive care unit

The objective of the study was to evaluate whether the introduction of patient-focused nursing care affected the number of seclusions and the length of time patients spent in seclusion, in an acute psychiatric unit. The study used a pre-intervention–post-intervention design and was conducted in an eight-bed locked unit within a large regional general hospital in Queensland, Australia. The medical records of all people who were secluded as part of their management while in hospital, during two 6-month periods, were retrospectively reviewed. Changes to the ways in which nurses conducted their daily activities were implemented during the time between the data collection periods. There were no differences between the groups with respect to the number of times a patient was secluded. However, following implementation of patient-focused care, there was a reduction in the length of time for which patients were secluded. The only change in medication administration was that post-implementation, Haloperidol was used in fewer seclusion episodes. The findings indicate that changes to nursing practice may result in closer monitoring of patients and a reduction in the time patients spend secluded in acute inpatient psychiatric settings.

Outcomes for elderly patients with mental illness following relocation from a stand-alone psychiatric hospital to community-based extended care units

Objective: To assess the outcomes for a group of elderly patients with mental illness following their discharge from a stand-alone psychiatric facility to seven extended care units (ECUs). Method: All patients (n = 60) who were relocated to the ECUs were assessed using a number of standardized clinical and general functioning instruments at 6 months and 6 weeks pre-move, and again at 6 weeks, 6 months and 18 months post-move. Results: By 18 months post-discharge, 13 of the 60 patients (21.7%) had died and seven others had been transferred to nursing homes. Those who died were older and had significantly higher levels of physical ill health when compared to those who did not die. Changes on measures of clinical and behavioural functioning in those who remained in the study did not reach statistical significance by 18 months post-move. However, participants did demonstrate improvements in quality of life with significantly higher scores on measures of social contact and community access. Conclusions: The mortality observed in the follow-up period is likely to be related to physical ill health and old age rather than the trauma associated with relocation. While overall functioning did not improve following relocation, patients had more independence and greater access to community-based activities.

Do stressful times call for team-based working? A study of psychiatric nurses in UK mental healthcase

Background: Team-based working is now an inherent part of effective health care delivery. Previous research has identified that team working is associated with positive mental health and well-being outcomes for individuals operating in an effective team environment. This is a particularly important topic in the health services context, although little empirical attention has been paid to mental-health services. Psychiatric nurses work on a day-to-day basis with a particularly stressful and demanding client group in an environment which is characterised by high demands, uncertainty, and limited resources. This paper specifically focuses on psychiatric nurses working in National Health Service (NHS) and casts some light on the ways in which effective team-based working can help to alleviate a number of occupational stressors and strains. Method: A questionnaire method (2005 NHS Staff Survey) was employed to collect data from 6655 psychiatric nurses from 64 different NHS Trusts. The hypotheses were concerned with four overall measures from the survey; effective team working, occupational stress, work pressure and social support. Hypothesis 1 stated that effective team working will have a significant negative relationship with occupational stress and work pressure. Further, Hypothesis 2 stated that social support from supervisors and co-workers will moderate this relationship. Findings: Data was treated with a series of regression analyses. For Hypothesis 1, working in a real team did have main effects on work pressure and accounted for 1.6 per cent of the variance. Using the Nagelkerke R square value, working in a real team also had main effects on occupational stress an accounted for approximately 2.8 per cent of the variance. Further, the Exp (B) value of 0.662 suggests that the odds of suffering from occupational stress are cut by 33.8 per cent when a psychiatric nurse works in a real team. Results failed to provide support for Hypothesis 2. The analysis then went on to adopt a unique approach for assessing the extent of real team-based working, distinguishing between real teams, and a number of pseudo team typologies, as well as the absence of teamwork all together. As was hypothesised, results demonstrated that psychiatric nurses working in real teams (ones with clear objectives, where-by team members work closely with one another to achieve team objectives and meet regularly to discuss team effectiveness and how it can be improved) experienced the lowest levels of stress and work pressure of the sample. However, contrary to prediction, results indicated that psychiatric nurses working in any type of pseudo team actually experienced significantly higher levels of stress and work pressure than those who did not report as working in a team at all. Discussion: These findings have serious implications for NHS Mental Health Trusts, which may not be implementing, structuring and managing their nursing teams adequately. Indeed, results suggest that poorly-structured team work may actually facilitate stress and pressure in the workplace. Conversely, well-structured real teams serve to reduce stress and work pressure, which in turn not only enhances the working lives and well-being of psychiatric nurses, but also greatly improves the service that the NHS provides to its users.