Stephen Elsom

Midwives and assessment of perinatal mental health

Accessible summary • Childbirth is a significant life event in which women may experience emotional as well as physical changes. • This study examined what midwives thought about their mental health skills and knowledge when they worked with women with a mental illness who had just had a baby. • They reported feeling ill equipped to work with women with mental illness as well as not being aware of the resources available to them and the mothers. • Midwives need to have appropriate education, knowledge and skills to work with this vulnerable group of women. Abstract Childbirth involves many psychological and emotional changes for women. The recent Commonwealth Government of Australia, National Perinatal Mental Health Action Plan (in 2008) recommends all pregnant and postnatal women have a psychosocial assessment including completion of the Edinburgh Postnatal Depression Scale. Midwives will assess all women at antenatal ‘booking in’ to maternity services. Currently, midwives receive little education regarding mental health assessment of women. This study explored the perceptions of midwives of their own mental health skills, knowledge and experiences, when working with women with mental illness in the perinatal period. An exploratory descriptive design was utilized to survey midwives across 19 maternity sites in Victoria, Australia. Clearly, midwives lack mental health skills and knowledge, describing their lack of confidence and feeling uncomfortable and unsafe when providing care for women with mental illness. They also report little knowledge of resources available to provide appropriate services for these women. The future direction for improving maternity care will require midwives to assess mental health needs of women, and refer them on, for timely intervention. It is critical midwives are prepared and able to make this kind of assessment.

Self-efficacy and locus of control affect management of aggression by mental health nurses.

The safe and effective management of aggression has become an increasingly critical skill for mental health nurses, particularly those working in acute inpatient settings. There is considerable evidence to suggest that the psychological constructs of self-efficacy and locus of control are closely related to work performance in a variety of occupations. By drawing upon literature published in the past 15 years, this paper highlights this evidence and draws attention to the relationship between self-efficacy and locus of control. The central argument of the paper is that there may be direct relationships among mental health nurses” self-efficacy, their degree of internality or externality in relation to locus of control, and their ability to safely and effectively manage aggressive incidents. We argue the need to further investigate these relationships and discover whether these variables can be modified through professional development activities.

Nurse Practitioners and Medical Practice: Opposing Forces or Complementary Contributions?

PURPOSE The medical profession in Australia has expressed concern about the expansion of nursing practice into areas that are traditionally the domain of medicine. Particular apprehension is raised in relation to the prescription of medications. This paper will consider and critique the argument that the standard of care provided by a nurse practitioner would be of lesser quality than that provided by a medical practitioner. CONCLUSIONS Despite the medical professions opposition for nurse practitioner roles, there is little evidence suggesting that the quality of services offered by a nurse practitioner would be inferior. PRACTICE IMPLICATIONS Available evidence suggests that care and treatment from nurse practitioners in primary health care is equal to that provided by medical practitioners.

Exploring the expanded practice roles of community mental health nurses

Significant changes to the delivery of mental health services have resulted in the expansion of the community mental health nursing role. This qualitative study was undertaken to explore the extent to which community mental health nurses are currently engaged in expanded forms of practice. Focus groups were undertaken with community mental health nurses (n = 27) from metropolitan and rural Victoria, Australia. Thematic analysis identified the following major themes: reported practice, consumers as beneficiaries of expanded practice, risk of harm and litigation, and barriers to expanded practice. The findings emphasize the need for significant changes in current legislation if expanded practice for nurses is to become a reality.

Identifying the core competencies of mental health telephone triage.

AIMS AND OBJECTIVES The primary aim of this study was to identify the core competencies of mental health telephone triage, including key role tasks, skills, knowledge and responsibilities, in which clinicians are required to be competent to perform safe and effective triage. BACKGROUND Recent global trends indicate an increased reliance on telephone-based health services to facilitate access to health care across large populations. The trend towards telephone-based health services has also extended to mental health settings, evidenced by the growing number of mental health telephone triage services providing 24-hour access to specialist mental health assessment and treatment. Mental health telephone triage services are critical to the early identification of mental health problems and the provision of timely, appropriate interventions. In spite of the rapid growth in mental health telephone triage and the important role these services play in the assessment and management of mental illness and related risks, there has been very little research investigating this area of practice. DESIGN An observational design was employed to address the research aims. METHODS Structured observations (using dual wireless headphones) were undertaken on 197 occasions of mental health telephone triage over a three-month period from January to March 2011. RESULTS The research identified seven core areas of mental health telephone triage practice in which clinicians are required to be competent in to perform effective mental health telephone triage, including opening the call; performing mental status examination; risk assessment; planning and action; termination of call; referral and reporting; and documentation. CONCLUSIONS The findings of this research contribute to the evidence base for mental health telephone triage by articulating the core competencies for practice. RELEVANCE TO CLINICAL PRACTICE The mental health telephone triage competencies identified in this research may be used to define an evidence-based framework for mental health telephone triage practice that aims to improve the quality, consistency and accuracy of telephone-based mental health triage assessment.

Vulnerable populations and multicentred research

There are many challenges facing researchers with projects requiring multicentred ethics approval. Achieving ethical approval at multiple sites, whether statewide or nationally, is a complex and time-consuming experience, compounded by the research process itself, as well as the recruitment of clinical sites and participants. Human ethics and research committees act as research gatekeepers and, as many research activities involve multiple applications and multiple approvals, can considerably delay the commencement of a project. A delay in ethics approval results in delays recruiting staff and participants, delays in the utilization of funding, and in delays regarding the progress and completion of projects. Such problems are additional problems for researchers of vulnerable populations, such as those in mental health or palliative care, where multicentred research is necessary to ensure the validity of the project itself. A current example of work that has required multicentred human ethics and research approval from around Australia is the establishment of the National Register of Antipsychotic Medication in Pregnancy. The guidelines for embarking on such a project with the requirement of multicentred ethical approval are described. Some of the issues, recommendations, and guidelines presented by the authors are taken from their experiences in establishing multicentred research projects.

Informal Role Expansion in Australian Mental Health Nursing

PURPOSE This study aims to determine the extent to which community mental health nurses are currently practicing beyond the traditional scope of nursing practice. DESIGN AND METHODS A self-administered questionnaire was distributed to community mental health nurses in Victoria, Australia. FINDINGS The majority of participants reported routine involvement in practices that would normally be considered beyond the scope of nursing practice, such as prescribing, ordering diagnostic tests, and referral to specialists. PRACTICE IMPLICATIONS The extent to which the current mental health service system is dependent upon nurses transgressing professional and legal boundaries warrants further study. Psychiatrists and community mental health nurses need to work collaboratively to understand their respective knowledge and skills and to be clear about how they take responsibility for client care.

Factors influencing cardiometabolic monitoring practices in an adult community mental health service

People with serious mental illness are reported to live up to 25 years less than the general population. Cardiovascular disease and diabetes risk factors, as well as mental health, treatment, lifestyle, service provision, and socioeconomic factors, all contribute to this health inequity. Cardiometabolic monitoring (CMM) is one strategy used to attend to some cardiometabolic risk factors. The present study aimed to explore factors that influence decisions to undertake CMM in an Australian adult community mental health service. A CMM audit tool was designed to capture demographic, clinical, and care-provision factors. A 6-month retrospective file audit from the total population of consumers of an adult community mental health service was undertaken, where no existing CMM guidelines or practices were in place. The study findings confirmed a higher prevalence of cardiometabolic disorders in the study population compared to the general population. Complete CMM occurred in 24% of the study population (n = 94). No consumer demographic, socioeconomic, or clinical characteristics, or care-provision factors, were found to be predictors of complete CMM. The random manner in which CMM was observed to occur in the study highlights the need for standardized CMM guidelines and capacity-building strategies to improve current CMM practices.

Mental Health Telephone Triage: Managing Psychiatric Crisis and Emergency

PURPOSE The study aims to identify and articulate how mental health telephone triage (MHTT) clinicians manage psychiatric crisis and emergency via the telephone. DESIGN AND METHODS An observational design was employed in the study. Wireless headsets were used to observe 197 occasions of MHTT. FINDINGS Clinicians use a range of practical strategies, therapeutic skills, and psychosocial interventions to manage psychiatric crises and emergencies via the telephone. PRACTICE IMPLICATIONS The evidence base for managing psychiatric crisis/emergency in MHTT is minimal. These findings contribute to the MHTT knowledge base and provide evidence-based strategies for high-quality emergency mental health care.

Experiencing antipsychotic discontinuation: results from a survey of Australian consumers

Despite high reported rates of antipsychotic non-adherence, little is known about consumer experiences during discontinuation. This study was designed to increase understanding of antipsychotic discontinuation from consumer perspectives. In 2011-2012, 98 Australian consumers involved with participating organizations completed an anonymous survey detailing past antipsychotic discontinuation attempts. Of the 88 participants who reported at least one discontinuation attempt, over half (n = 47, 54.7%) reported stopping without clinician knowledge or support. This group was 35% (confidence interval 15.4-54.6%) more likely to stop abruptly than those (n = 41, 45.3%) stopping with clinician support (P = 0.002). Only 10 participants (23.3%) recalled being given information about discontinuation symptoms other than relapse; however, 68 participants (78.2%) reported experiencing a range of discontinuation symptoms including physical, cognitive, emotional, psychotic or sleep-related disturbances. Findings cannot be readily generalized because of sampling constraints. However, the significant number of participants who reported discontinuation symptoms, in addition to psychosis, is consistent with previous research. This study provides new insight into consumer motivations for discontinuation and possible problems in clinical communication that may contribute to frequent non-collaborative discontinuation attempts. Mental health nurses, who play a pivotal role in medication communication events, may benefit from increased awareness of consumer perspectives on this topic.Accessible summary The aim of the survey was to gain an understanding of consumer experiences of antipsychotic discontinuation. Incorporating consumer perspectives into practice may help clinicians to better understand discontinuation decisions and experiences. This topic may be of particular interest to mental health nurses who play an important role in supporting consumers with medication related decisions. The survey highlighted that consumers often try to discontinue antipsychotic medication, frequently without the knowledge or against the advice of clinicians. Consumers who discontinued in such unsupported ways appeared more likely to stop abruptly. Abrupt cessation has been associated with a number of increased risks in the literature. Negative discontinuation symptoms such as difficulty sleeping, mood changes, problems concentrating, increased psychotic experiences and physical problems were reported by more than half of the survey participants. Many consumers reported that they did not feel adequately informed about how to most safely stop or what to expect when stopping. These findings add new knowledge to our understanding of why consumers discontinue antipsychotics. The problems participants reported in their relationship with clinicians, in particular, helps to explain why so many consumers may stop in secret. The need to improve communication between consumers and clinicians around the common experience of antipsychotic discontinuation is highlighted. Findings also highlight the need to conduct further research into discontinuation symptoms and how clinicians might better educate and support consumers who are experiencing them. Abstract Despite high reported rates of antipsychotic non-adherence, little is known about consumer experiences during discontinuation. This study was designed to increase understanding of antipsychotic discontinuation from consumer perspectives. In 2011–2012, 98 Australian consumers involved with participating organizations completed an anonymous survey detailing past antipsychotic discontinuation attempts. Of the 88 participants who reported at least one discontinuation attempt, over half (n = 47, 54.7%) reported stopping without clinician knowledge or support. This group was 35% (confidence interval 15.4–54.6%) more likely to stop abruptly than those (n = 41, 45.3%) stopping with clinician support (P = 0.002). Only 10 participants (23.3%) recalled being given information about discontinuation symptoms other than relapse; however, 68 participants (78.2%) reported experiencing a range of discontinuation symptoms including physical, cognitive, emotional, psychotic or sleep-related disturbances. Findings cannot be readily generalized because of sampling constraints. However, the significant number of participants who reported discontinuation symptoms, in addition to psychosis, is consistent with previous research. This study provides new insight into consumer motivations for discontinuation and possible problems in clinical communication that may contribute to frequent non-collaborative discontinuation attempts. Mental health nurses, who play a pivotal role in medication communication events, may benefit from increased awareness of consumer perspectives on this topic.