Dave Carlyle

Disorder-specific psychosocial interventions for bipolar disorder—A systematic review of the evidence for mental health nursing practice

AIMS To systematically review the evidence for the efficacy of psychosocial interventions for bipolar disorder and examine the implications for mental health nursing practice. BACKGROUND Bipolar disorder is associated with significant psychosocial impairment and high use of mental health services. Generally medication is effective in the treatment of acute episodes but there is increasing evidence that while a large majority of patients recover from these episodes of mania and/or depression, many do not achieve a functional recovery. In response a range of psychotherapies have either been adapted or developed. DESIGN An extensive review of the literature was performed using Medline, Cinahl and PsycINFO databases and 35 relevant research studies were chosen that met inclusion criteria. FINDINGS All the identified psychosocial interventions were structured, adhered to manualized protocols and had solid evidence demonstrating their effectiveness when used as an adjunct to psychopharmacology. The identified psychosocial interventions all incorporated some features of a psycho-education including developing an acceptance of the disorder, awareness of its prodromes and signs of relapse, and communication with others; and several emphasise regular sleep and activity habits. CONCLUSION Mental health nurses have an important role to play in integrating psychosocial interventions into their clinical practice settings and in conducting high quality trials of their clinical effectiveness. Nurses are well-positioned to lead pragmatic trials of the clinical effectiveness of these psychosocial interventions in mental health services because of their experience and expertise in working with patients with bipolar disorder.

Clinical formulation for mental health nursing practice

There are problems for mental health nurses in using psychiatric diagnoses as outcomes of their nursing assessments and nursing diagnoses present similar issues. However, there is a need in practice to link the assessment to nursing interventions in a meaningful way. This paper proposes that the clinical formulation can be regarded as central to providing this cohesion. The formulation does not merely organize the assessment findings but is also an interpretation or explanation, made in consultation with the client, of what meaning can be attributed to the issues explored in the assessment process. Because this interpretation is dependent on both the clients and the nurses explanatory frameworks, there are multiple ways of developing the formulation. It is also an evolving and dynamic statement of understanding. A case example is provided in the paper to illustrate how the same case can be interpreted in different ways and the implications this has for the nursing interventions provided.

‘Violence is Not Part of Our Job’: A Thematic Analysis of Psychiatric Mental Health Nurses’ Experiences of Patient Assaults from a New Zealand Perspective

This paper describes psychiatric mental health nurses’ (PMHN) experiences of patient assaults within mental healthcare settings using a thematic analytical approach. The aim of the study was to explore and describe psychiatric mental health nurses’ experiences of patient assaults. The major findings of the study related to the nature and impact of assaults and supportive strategies associated with violence perpetrated by patients against psychiatric mental health nurses. Perpetrator risk factors for patients include mental health disorders, alcohol and drug use and the inability to deal with situational crises. The injuries sustained by nurses in the context of the study include lacerations, head injuries, dislocations and bruises. Psychological harm has also occurred, including quite severe mental health problems, such as post-traumatic stress disorder. Protective strategies for combating negative consequences of workplace violence include practice of self-defence, social support and a supportive and consultative workplace culture with access to counselling services and assistance in all aspects, including finances. The paper concludes that while healthcare employers need to provide better support services to the healthcare professionals who are assaulted, the legal system also needs to acknowledge that assaults against nurses are a violation of human rights and violence should not to be tolerated as part of working in mental healthcare settings.

Effectiveness of interventions to improve medication adherence in bipolar disorder

Objective: To identify interventions that improve medication adherence in bipolar disorder. Method: A review of the literature from 2004 to 2011 was conducted using Medline and manual searching. Results: Eleven studies were identified as meeting inclusion criteria. Five studies demonstrated improved medication adherence. No characteristics of the interventions, clinical characteristics of the groups or methodological factors distinguished those psychosocial interventions that demonstrated improvement from those that did not. Conclusions: While only a few interventions improved adherence, most improved clinical outcomes. Issues were also identified about the way in which adherence is defined. It is proposed that incorporating patient preferences into measures of adherence within the context of a disorder-specific psychosocial intervention may provide an approach that demonstrates both improved adherence and improved clinical outcomes. However this requires further research.

Feeling out of control: a qualitative analysis of the impact of bipolar disorder

Bipolar disorder is a chronic and recurrent disorder with fluctuating symptoms. Few patients with bipolar disorder experience a simple trajectory of clear-cut episodes, with recovery typically occurring slowly over time. The chronic and disabling course of the disorder has a marked impact on the persons functioning and relationships with others. The objectives of this study were to investigate the impact of bipolar disorder on the lives of people diagnosed with this disorder. The method used was a general inductive qualitative approach. Twenty-one participants were interviewed between 2008 and 2009 about how they had experienced the impact of bipolar disorder. The interviews were audio-taped and transcribed. The core theme that emerged was the participants were feeling out of control. Their own reactions and the reactions of others to the symptoms of bipolar disorder contributed to this core theme. The core theme was constituted by feeling overwhelmed, a loss of autonomy and felling flawed. Mental health nurses can help facilitate a sense of personal control for people with bipolar disorder by exploring what the symptoms mean for that person and implementing strategies to manage the symptoms, address social stigma and facilitate active involvement in treatment.

Models of care delivery in mental health nursing practice: a mixed method study.

The aim of this study was to identify the conceptual models that underpin mental health nursing care in clinical settings. This study is a modification of a previous study which evaluated the influence of implicit models of mental disorder on processes of decision making within community-based teams. Participants completed questionnaires in response to a scenario. A range of explanatory conceptual models were identified in respect to aetiology, treatment and recovery. In a forced choice the participants ranked a medical model of care above other models as underpinning care delivery. The content analysis found that the participants used a psychodynamic framework for understanding the causes of mental distress but described the nursing interventions in terms of supporting a medical model of care. Nursing care is dominated by a medical model which constrains mental health nursing. This potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting. A range of psychosocial approaches to mental health care delivery have been developed, but there seems to be problems with their implementation in practice. Further research is required to explore how broader therapeutic interventions can be implemented by nurses within multidisciplinary systems of mental health care delivery.

The process of change in psychotherapy for depression: helping clients to reformulate the problem

There is increasing interest in mental health nurses delivering structured short-term evidence-based psychotherapies such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT); however, while there is evidence of the efficacy of psychotherapy for depression, there is limited understanding of the treatment processes. Data were drawn from audio tapes of CBT and IPT sessions for treatment of depression. The transcripts of the initial, middle and final psychotherapy sessions of 40 clients were analysed. A thematic analysis was conducted to identify what was occurring in the sessions, how the client was describing psychotherapy and how the client was describing improvement or lack of improvement in depressive symptoms. There were differences in descriptions of therapy and the experience of depression between clients who responded and those who did not respond to therapy that were related to improvement in symptoms but not to the specific therapy. These differences were in the clients engagement with the language of therapy, sense of optimism about the particular model of psychotherapy, ability to examine their own role in the problem and desire to engage with new ways of being in their lives. Clients who responded to CBT or IPT had flexibility to develop new ways of thinking and acting, the ability to accept responsibility for their role in the identified problem and were willing to risk change.

Is open access sufficient? A review of the quality of open‐access nursing journals

The present study aims to review the quality of open-access nursing journals listed in the Directory of Open Access Journals that published papers in 2013 with a nursing focus, written in English, and were freely accessible. Each journal was reviewed in relation to their publisher, year of commencement, number of papers published in 2013, fee for publication, indexing, impact factor, and evidence of requirements for ethics and disclosure statements. The quality of the journals was assessed by impact factors and the requirements for indexing in PubMed. A total of 552 were published in 2013 in the 19 open-access nursing journals that met the inclusion criteria. No journals had impact factors listed in Web of Knowledge, but three had low Scopus impact factors. Only five journals were indexed with PubMed. The quality of the 19 journals included in the review was evaluated as inferior to most subscription-fee journals. Mental health nursing has some responsibility to the general public, and in particular, consumers of mental health services and their families, for the quality of papers published in open-access journals. The way forward might involve dual-platform publication or a process that enables assessment of how research has improved clinical outcomes.

Implementing and Maintaining Nurse-Led Healthy Living Programs in Forensic Inpatient Settings: An Illustrative Case Study

BACKGROUND: Healthy living programs (HLPs) within the context of mental health units are an applied response to the concerns of metabolic syndrome and the associated physical illnesses to which people with serious mental illness are susceptible. OBJECTIVE: To illustrate how nurses, with other health professionals and service users, have established and maintained HLPs in two locked forensic mental health units in New Zealand. DESIGN: This illustrative case study adopts a multimodal approach to data collection and analysis. Across two programs, interviews were undertaken with service users (n = 15) and staff (n = 17), minutes of meetings were analyzed for major decision points, and clinical notes were reviewed to identify which service-user health status measures (body mass index, glucose tolerance test results, blood pressure, and medication use) were recorded. RESULTS: Similarities were identified in the way the HLPs were implemented and maintained by champions who advocated for change, challenged staff attitudes, secured funding, and established new systems and protocols. Successful implementation depended on involvement of the multidisciplinary team. Each program operated within a different physical environment and adopted its own philosophical approach that shaped the style of the program. The HLPs had an impact on nurses, other staff, and on the culture of the institutions. The programs raised dilemmas about restrictions and risk versus autonomy and self-management. CONCLUSION: Understanding the effects of the clinical and philosophical contexts in which HLPs are established and the way challenges and benefits are affected by context has practical significance for the future development of health programs in forensic settings, prisons, and general mental health units.

A nurse-led interdisciplinary approach to promote self-management of type 2 diabetes: A process evaluation of post intervention experiences

RATIONALE, AIMS AND OBJECTIVES Self-management of type 2 diabetes through diet, exercise and for many medications, are vital in achieving and maintaining glycaemic control in type 2 diabetes. A number of interventions have been designed to improve self-management, but the outcomes of these are rarely explored from a qualitative angle and even fewer through a process evaluation. METHOD A process evaluation was conducted using a qualitative design with participants randomized to an intervention. Seventy-three people living with type 2 diabetes and hyperglycaemia for a minimum of 1 year, randomized to one of two interventions (n = 34 to an education intervention and n = 39 to an education and acceptance and commitment therapy intervention) completed stage one of the process evaluation, immediately following the intervention through written feedback guided by open-ended questions. A purposive sample of 27 participants completed semi-structured interviews at 3 and 6 months post intervention. Interview data were transcribed and data analysed using a thematic analysis. RESULTS The majority of participants described an increase in knowledge around diabetes self-management and an increased sense of personal responsibility. Participants also described changes in self-management activities and reflected on the challenges in instigating and maintaining change to improve diabetes management. CONCLUSION The complexities of implementing change in daily life to improve glycaemic control indicate the need for ongoing support post intervention, which may increase and maintain the effectiveness of the intervention.