David Lees

Therapeutic engagement between consumers in suicidal crisis and mental health nurses

Registered nurses within public mental health services play crucial roles in helping people recover from suicidal crisis. However, there is a lack of understanding of how care is experienced in this context, and available evidence suggests that nurses and consumers are often dissatisfied with the quality of care. There is thus an imperative to generate understanding of needs and experiences of both groups with a view to informing practice development. This article summarizes qualitative findings from a multimethod study undertaken in Australia, which surveyed and interviewed mental health nurses who had recent experience of caring for consumers in suicidal crisis in a hospital setting, and interviewed consumers who had recovered from a recent suicidal crisis. A framework was developed to guide the study and support ethical imperatives; in particular, the promotion of consumer well-being. The findings highlight that therapeutic interpersonal engagement between nurses and consumers was central to quality care. This was particularly noted, as engagement could help reduce consumer isolation, loss of control, distress, and objectification of the delivery of potentially-objectifying common interventions. Of concern, the results indicate a lack of therapeutic engagement from the perspective of both consumers and nurses. Recommendations to promote fuller therapeutic engagement are presented.

Recovery-oriented Care and Leadership in Mental Health Nursing

A recovery-oriented mental health service actively involves consumers as fully as possible in all aspects of their care, empowering them to establish and strive for individual goals and to develop ...

Lip service: Public mental health services and the care of Aboriginal and Torres Strait Islander peoples

The failure of public mental services in Australia to provide care deemed culturally safe for Aboriginal and Torres Strait Islander people has persisted despite several national reports and policies that have attempted to promote positive service change. Nurses represent the largest professional group practising within these services. This article reports on a multisited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about public mental health services and the services they provided to Aboriginal and Torres Strait Islander people. During the fieldwork, mental health nurses described the constricting effect of the biomedical paradigm of mental illness on their abilities to provide authentic holistic care focused on social and emotional well-being. Despite being the most numerous professional group in mental health services, the speciality of mental health nursing appears unable to change this situation and in many cases maintain this status quo to the potential detriment of their Aboriginal and Torres Strait Islander service users.

Rule Breaking: Some Positive and Negative Implications for Professional Standards and Clinical Practice

Rules regulate much of human activity, and permeate the professional lives of nurses, informing our scope of practice and professional and ethical behaviors. In the complex world of health care provision, where demands on staff can be high, and critical voices representing the best interests of health care consumers can be lacking, the testing and breaking of rules by nurses is not uncommon (Collins, 2012). In this column, we explore rule breaking and the implications it can have for employees, organizations and employers and, ultimately, health care consumers. Understanding how and why people bend or break rules may assist nurses to realize better workplace communication and interpersonal relationships and to better negotiate and help evolve the complexities of health care provision. Breaking a rule may be an act of neglect or self-interest (Nogami & Yoshida, 2013) and can place an individual or group at risk. Alternatively, rule breaking may be an act of resistance, pragmatism or valuable creativity (Collins, 2012). From a psychological perspective there are numerous explanations for why a person may break rules, including: as an act of creativity (or because someone is creative enough to ‘reframe’ the event as acceptable or necessary); to establish or reinforce status within a group (breaking the rules can make oneself more powerful); to bond with or support others (the Robin Hood defense); to ensure one is not disadvantaged if others are perceived to have been advantaged through rule breaking; because it is morally the right thing to do; due to lack of self-awareness that one is actually breaking a rule; or because rule breaking has become normalized and is thus not consciously acknowledged (Pincott, 2014). In a general context, employees who break rules may be seen to be demonstrating deviant or counterproductive behavior (Bryant, Davis, Hancock, & Vardaman, 2010). However, in some circumstances rule breaking can have a positive influence on the workplace. Indeed, Buckingham and Coffman (1999) urge innovative business managers to “first, break all the rules” with the intention of devolving traditional power structures, empowering employees and fostering innovation. Such pro-social rule breaking (PSRB) is defined as: “any instance where an employee intentionally violates a formal organizational policy, regulation, or prohibition with the primary intention of promoting the welfare of the organization or one of its stakeholders” (Morrison, 2006, p. 6). PRSB reflects the reality that situations and contexts often warrant a flexible approach rather than rigid adherence to rules that may be outdated or detrimental to the organization or employee (Vardaman, Gondo, & Allen, 2014). Employees who experience a high level of autonomy in their roles are well placed to break the rules more often. These employees may perceive themselves to be effective problem solvers, feel a greater sense of empowerment and control, and be more self-sufficient (Morrison, 2006). Employees may engage in PSRB behaviors for altruistic reasons including being able to perform their role more effectively, helping peers, and assisting others who are important to them such as a client (Bryant et al., 2010; Morrison, 2006). It is important to acknowledge, however, that even PSRB may have repercussions. Indeed, some employees may feel that violations of the rules are unacceptable by any staff member, including management (Bryant et al., 2010) and rule breaking by others may negatively influence an individual employee’s perceptions of what is or is not acceptable behavior in the workplace. If, for example, an employee perceives that the rules pertaining to a manager’s behavior have been unjustly broken or overlooked the employee may feel that their “psychological contract” with the employer has been “broken” (Bryant et al., 2010, pp. 104–105). This may negatively impact the employee causing them to become disillusioned and potentially reducing their job satisfaction and performance (Bryant et al., 2010). An employee who becomes aware that a peer has participated in PSRB is more inclined to engage in PSRB themselves (Morrison, 2006). This demonstrates that once someone breaks the rule, even in support of the organization’s best interests, then others may perceive that this is acceptable behavior irrespective of the consequences (Vardaman et al., 2014). There will, however, always be some individuals who find rule breaking abhorrent or too risky to contemplate. Irrespective of the situation such people are unlikely to violate the rules (Vardaman et al., 2014). This does not mean that people engaging in PRSB are “bad”

Friendship and Mental Health

Friendship can be vitally important to our mental health and well-being. It offers experiences highlighting our interconnectedness and illustrating actions and qualities that may guide us in caring...

Loyalty in the Workplace: Some Considerations for Mental Health Nurses

Abstract Nurses are expected to be loyal to their patients, employer and the nursing profession, while also remaining ‘loyal’ to their own values and aims as both a person and clinician. Loyalty therefore is of central importance to how we relate to people in personal and professional relationships and may affect our attitude to the organization we work for. This column explores the concept of loyalty, and its role in professional relationships, behaviour and practice. Ways that loyalty can be influential in achieving personal, patient and organizational outcomes are explored and the potential to enhance loyalty is considered.

Therapeutic Relationships and Safety of Care in Iranian Psychiatric Inpatient Units

Abstract Enhancing therapeutic relationships between patients and staff is of central importance to improve the quality and safety of care in psychiatric inpatient units. However, there is limited evidence as to how therapeutic relationships may be enabled in this specific context. This paper presents findings of a study that explored the link between therapeutic relationships and safety in Iranian psychiatric inpatient units. In this exploratory, descriptive study, seven patients at the point of discharge and 19 staff in psychiatric inpatient units in Iran were interviewed regarding their experiences of care. The quality of staff-patient relationship in providing a safe environment was categorized into two groups of “facilitators” and “inhibitors”. Facilitators of a safe environment included “supportive relationship with patients” and “improving patient capacity for self-efficacy/self-control”. Inhibitors, on the other hand, included “detachment from patients” and “domination over patients”, which ultimately limited safety on the ward. Findings indicate interrelated environmental, patient and staff factors mediating the potential for therapeutic relationships and quality and safety of care. Findings suggest the need for more effective preparation and support for staff working within psychiatric inpatient settings. In addition, environments more conducive to collaborative recovery-oriented practice are required to enhance therapeutic relationships and improve quality and safety of care. Both individual staff responsibility and effective leadership are required to realize change.

Mental health nursing practice and Indigenous Australians : a multi-sited ethnography

Abstract Criticism of public mental services provided to Indigenous Australians have persisted over the last two decades, despite several national reports and policies that have attempted to promote positive service change. Mental health nurses represent the largest professional group practising within these services. This paper reports on a multi-sited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about specialist mental health nursing practice and Indigenous Australians. The study found a disunited approach to practice during the fieldwork. Practice was expressed as a series of individual constructions built upon the nurses’ beliefs about Indigenous Australians and their experiences in practice with these peoples. The criticism of mental health services from Indigenous communities was understandable to the mental health nurses, but how they could address this through their individual practices was not always clear to them. The actions by public mental health services to improve cultural safety through generic training related to the broad area of Indigenous health and health service needs, does not appear to evolve into informed specialist mental health nursing practice for Indigenous Australian service users.

High Hopes and Expectations: Consumer Disappointment and Recovery

The reality of everyday life is that hopes or expectations for certain outcomes are not always realized. Whether it is a competitive sports game, attaining the requisite marks to get into university, an application for a job, or facing a challenging family or health issue, outcomes are not always favorable. If expectations are not moderated or managed accordingly, then disappointment may ensue. In regards to mental health care, the promotion of help seeking and a recovery model of care can result in expectations of mental health service that do not match outcomes. This column explores the concept of disappointment in relation to the experiences of mental health care consumers and their recovery journeys. Disappointment is a negative, cognitively determined emotion (Giorgetta, Zeelenberg, Ferlazzo, & D’Olimpio, 2012), the central feature of which is the non-fulfillment of an outcome hoped for or expected. The way disappointment is experienced is influenced by hope (desire and promise). High hopes are more likely to result in intense disappointment as one’s expectations are that success (not failure) will be more likely than if only a half-hearted attempt was made (Van Dijk, Van Der Pligt, & Zeelenberg, 1999). When the desired outcome is uncertain, however, one may protect oneself from the experience of disappointment by underestimating the likelihood of achieving a specific outcome (Van Dijk, Zeelenberg, & Van Der Pligt, 2003). Lowered expectations may also decrease the chance of experiencing disappointment, as there is less chance that the expectation will exceed the obtained outcome (Van Dijk et al., 2003). Hope is a central feature of recovery-oriented mental health care (Kidd, Kenny, & McKinstry, 2015). Recovery orientation of service involves a shift from the prioritization of outcomes from traditional ‘expert’ clinical perspectives, to more fully establishing and working towards individual consumer goals. In society, awareness of mental health issues has increased, help seeking behavior is promoted, and the evidence base indicates the potential for effective treatment of mental disorders. In this context, hopes for recovery may be high when a person seeks or receives mental health service. Similarly, clinicians (mental health nurses in this instance) may set high hopes for consumer outcomes and the fuller realization of a recovery model of care. However, gaps between expectations (potential) and outcomes (reality) are common and potentially highly problematic (Cleary, Horsfall, O’Hara-Aarons, & Hunt, 2013; Cutcliffe, Santos, Kozel, Taylor, &

Capitalising on Engagement: An Underutilised and Undervalued Resource in Healthcare

The increased demand for mental health services, in turn, impacts the capacity and capability of services as well as clinicians to provide quality care. Authentic engagement is central to realising consumer focused and recovery-oriented mental healthcare in this context. Therapeutic engagement between consumers and staff, consumer engagement within their community, and staff engagement within the workplace and with their professional ideals and standards, may be seen as interdependent forms of engagement maximising and reflecting potential and positive outcomes. The purpose of this column is to briefly revisit some issues pertaining to engagement with the aim of increasing awareness of the importance of this attribute as it applies to consumers and nurses. Therapeutic engagement between clinicians and consumers is at the heart of quality care (Cleary, Horsfall, O’Hara-Aarons, Jackson, & Hunt, 2012; Lees, Procter, & Fassett, 2014; Peplau, 1988). However, engagement in this sense is widely under realised (Mullen, 2009), and there are calls to revisit this concerning limitation (Cutcliffe, Santos, Kozel, Taylor, & Lees,