Frontline clinical staff, typically nurses, are routinely faced with the dilemma of managing challenging, defiant and sometimes unsafe behaviours. Structures of ward rules, regulations and ‘behavioural expectations’ are often employed in hospital environments in service of regulating these behaviours and ensuring collective well-being. Adolescent inpatient populations, however, pose unique and particularly complex challenges for managing behavioural expectations, given the unique needs and inherent tempestuousness of this developmental period. This article presents a critical review of the existing literature on behavioural expectations for inpatient units, which is largely bereft of adolescent-specific guidelines. Relevant theoretical perspectives are examined that lend understanding to the management of adolescent behaviour. Finally, drawing from neurodevelopmental, attachment and socio-evolutionary theory, guiding clinical principles and recommendations are derived for best practice in managing challenging adolescent behaviour in hospital settings.
For patients with mental illnesses (MIs), emergency departments (EDs) are often the entry point into the healthcare system, or their only resort for quickly accessing mental health treatment. A better understanding of the various barriers justifying high ED use among patients with MIs may help recommend targeted interventions that better meet their needs. This explorative qualitative study aimed to identify such barriers and the solutions brought forth to reduce ED use based on the perspectives of clinicians and managers working in EDs, other hospital departments or the community sector. Interviews were conducted between April 2021 and February 2022; 86 mental health professionals (22% were nurses) from four large urban ED sites in Quebec (Canada) were interviewed. Barriers were identified in relation to patient profiles, healthcare system and organisational features and professional characteristics. The key barriers that were found to explain high ED use were patients having serious MIs (e.g., psychotic disorders) or social issues (e.g., poverty), lack of coordination and patient referrals between EDs and other health services, insufficient access to mental health and addiction services and inadequacy of care. Very few solutions were implemented to improve care for high ED users. Better deployment of ED interventions in collaboration with outpatient care may be prioritised to reduce high ED use for patients with MIs. Improvements to the referral and transfer processes to outpatient care, particularly through care plans and case management programs, may be implemented to reduce high ED use and improve outpatient care among patients with multiple health and social needs.
To critically synthesise the literature on the lived experience of young adults about their transition to adult mental health services including the perspectives of key people in their world: parents, carers and clinicians. Young people within child and adolescent mental health services are usually required to transition to adult mental health services at the age of 18, despite evidence showing cognitive and emotional development impacted by childhood trauma, illness and adverse life events. This qualitative systematic review searched relevant electronic databases, policy documents, grey literature and theses examining original qualitative peer-reviewed studies published from 2009 to 2022 in English. The process utilised the PRISMA guidelines and the quality of papers assessed by the JBI critical appraisal tool. Nine papers met the criteria for inclusion in the review. The results indicate that qualitative research listening to the voices of young people transitioning to adult mental health services is a rarity. Even fewer papers examine the perspectives of key people in their lives: this review has critically synthesised the literature on the lived experience of young adults about their transition to adult mental health services including the perspectives of key people in their world: parents, carers and clinicians. The main themes identified include: age 18 is not a helpful trigger to transition; young people want more individualised planning; parents want more involvement and clinicians open up about a challenging nexus with adult mental health services.
Therapeutic relationships are critical in the treatment of mental health disorders. Some clients experiencing mental health disorders display conflict behaviour—for example, suicidal or self-harming behaviour, threats of or actual aggression, and various psychotic behaviours—which presents significant challenges for care professionals. In inpatient mental health units, where interactions with mental health nurses are frequent, managing conflict behaviour is crucial to maintaining care quality and fostering therapeutic progress. This study aims to describe nurses' perspectives on fostering therapeutic relationships while working with clients who display conflict behaviour. Qualitative research was conducted in a specialised treatment setting for such clients by means of individual semi-structured interviews and a focus group interview with nurses. The results show that the nurses' primary focus is on cooperating with clients and colleagues. Regardless of conflict behaviour, nurses consistently invite clients to cooperate. To do so, they must manage their own emotions and expectations, emphasise the clients' responsibility and reduce the opportunities for conflict behaviour. The unit structure helps nurses by reducing ambiguity regarding treatment policies and inconsistencies in nurse–client interactions and allows nurses and clients to experience feelings of safety. To work with conflict behaviour, nurses need to feel valued and supported by their colleagues and have adequate time and resources. In conclusion, this study shows how nurses foster therapeutic relationships with clients who display conflict behaviour by focusing on cooperation, structure and safety.
Severe mental illnesses (SMIs) represent a significant public health challenge with substantial personal, economic and societal burdens. Despite treatment advances, recovery outcomes for SMI patients remain variable. This study aimed to investigate the influence of personal and psychosocial factors on recovery among SMI patients in community health settings. This cross-sectional study was conducted in 23 community health service centres in Nanjing, China. We recruited 924 participants diagnosed with SMIs, using a random sampling method. The relationships between individual, psychosocial factors and patients' recovery status were analysed by multiple linear regression. The mediation effect of medication adherence was further tested by the Sobel test with bootstrapping. The mean score of the Morningside Rehabilitation Status Scale (MRSS) of 924 patients with SMIs was 49.82 ± 41.52. The main influencing personal factors of recovery status were age, marital status, education, average annual income and duration of illness. Patients who were accepted by their families tended to have better recovery outcomes, while stigma and social impairment may hinder recovery. Medication adherence played a mediating role between psychosocial factors and recovery status. This study highlights the crucial role of psychosocial factors in the treatment and recovery of SMI patients. Furthermore, medication adherence emerged as a mediating factor. Implementing targeted interventions and policies addressing identified psychosocial barriers can offer promising avenues for improving recovery outcomes for SMI patients in community settings.
In addiction treatment, harm reduction is a philosophy that aims to reduce the harms from ongoing alcohol and other drug use. Although abstinence may be the ‘gold standard’ in reducing harm from ongoing alcohol and other drug use, harm reduction recognises that abstinence may not be achievable for certain individuals. Accordingly, harm reduction is used to enable medical or mental health treatment for individuals who continue to use alcohol and other drugs, providing a form of care which meets individuals where they present to healthcare facilities. Harm reduction accepts ongoing alcohol and other drug use, while providing a traditionally marginalised cohort of individuals access to healthcare services. In this perspective paper, we argue that the role of nurses in promoting and utilising harm reduction as part of their regular practice is essential to both reducing harm from alcohol and other drug use, engaging individuals who use alcohol and other drugs in healthcare services, and providing a means to accept individuals as they are to build trust and rapport for engagement in addiction treatment when they are ready, and at their own pace. Nurses, by virtue of their role and number in the healthcare landscape (approximately 28 million globally), are ideally placed to implement harm reduction in their practice to achieve better outcomes for individuals who use alcohol and other drugs.
Mental health conditions such as anxiety, depression and psychosis represent a global health challenge. Stigma surrounding mental health continues to hinder help-seeking behaviours for people with mental illness and as this study demonstrates, nursing students as well. However, if student nurses are reluctant to seek help for mental health issues, how can others be expected to do so? This reluctance poses challenges in mental health nursing, impacting both care provision and nursing education. The present study seeks to explore the influence of traditional versus non-traditional mental health clinical placements on second-year nursing students' stigmatising beliefs and intentions to seek help for mental health issues. Employing a prospective cohort design using the TREND checklist, the study sampled second-year nursing students assigned to either traditional hospital-based or non-traditional recovery-focused mental health clinical placements. Using validated scales, stigmatising beliefs and help-seeking intentions were measured before and after the placements. Statistical analyses were conducted to assess changes in these variables over time and across placement settings. A significant impact of placement setting on help-seeking intentions was observed, with students in non-traditional placements showing an increased willingness to seek help. Additionally, non-traditional placements were found to significantly reduce stigmatising beliefs in all measured domains, suggesting that these settings may provide a more conducive environment for fostering positive attitudes towards mental health. Recovery-focused placements appear to offer experiences that can diminish stigma and encourage more positive perceptions and intentions related to mental health support.
Pregnant and parenting people (PPP) experience complex challenges when seeking recovery from substance use disorders (SUD). Using a community-based participatory research approach, researchers partnered with PPP seeking recovery from SUD to explore supports needed in their communities. Findings are reported in adherence with the consolidated criteria for reporting qualitative research. Thirty PPP were recruited from a residential drug recovery facility in the Southeastern United States. Participant interviews were conducted in-person or virtually. PPP were asked to identify existing and needed parenting and recovery supports in their communities. Interviews were transcribed, verified for accuracy and coded using NVIVO software. Thematic analysis was framed by the Substance Abuse and Mental Health Services Administration (SAMHSA) eight dimensions of wellness, which reflect wellness standards across life domains. Participants identified internal and external challenges including feelings of guilt and shame, treatment access issues, lack of recovery support, grief and loss and inadequate instrumental support. Needed supports were broadly categorised as parenting resources, childcare resources, housing supports, recovery supports, occupational training and assistance and spirituality resources, and then evaluated and sorted based on appropriate fit within the SAMHSA's eight dimensions of wellness. Highest perceived needs fit within Intellectual, Emotional, Spiritual and Environmental wellness dimensions, respectively. Healthcare providers promoting recovery for PPP should focus on support needs within SAMHSA's dimensions of wellness and develop strategies that address the full range of these critical wellness dimensions. Intellectual, emotional and tangible environmental supports including parenting and recovery skills training, accessible mental health care and residential housing with childcare availability are essential for long-term recovery and positive parenting.
Crisis Resolution Home Treatment (CRHT) teams have become a widespread alternative to psychiatric hospitalisation. Despite their popularisation, Malta has only recently introduced a CRHT team. The aims of the current study were to investigate (i) patient characteristics, (ii) factors influencing patients' length of follow-up (LoFU) and (iii) predictors of clinical outcomes. Descriptive and quantitative non-identifiable data were collected and analysed for patients utilising the CRHT service within its first 2 years of operation (n = 643). One-way ANOVA tests investigated influencing factors for LoFU, whereas binary logistic regressions deduced predictive factors for clinical outcomes. Patients without acute psychiatric disorders had the shortest LoFU, indicating that the team received inappropriate referrals. Patients were most likely to have extended LoFU if they were diagnosed with OCD & related disorders and were most likely to be diagnosed with an underlying personality disorder if they were diagnosed with anxiety & phobic disorders. Continuity of care facilitates discharge planning. Patients receiving the CRHT service in Malta are most comparable with health systems that prefer to hospitalise patients with a higher risk profile. The high occurrence of personality disorders necessitates staff to have interdisciplinary knowledge and an appropriate skill mix.
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