Moral distress in the critical care air transport nurse.

BACKGROUND: Moral distress in healthcare providers occurs when the perceived right action cannot or is not taken and results in a loss of moral integrity. Critical Care Air Transport (CCAT) nurses are elite U.S. Air Force (USAF) clinicians who provide healthcare during transport of injured military members. CCAT nurses are vulnerable to physical and psychological stressors, including fatigue, multiple traumas, limited resources and ethical dilemmas. PURPOSE: The purpose of this study was to explore moral distress in USAF CCAT nurses. METHODS: Using interpretative hermeneutic phenomenology, we described the lived experience of moral distress in 15 CCAT nurses. FINDINGS: Seven themes emerged to describe the CCAT nurses experiences of moral distress. These include: Not Prepared, Agent of Healing or Agent of Harm, Live or Let Die, Robbing Peter to Pay Paul, Ever Decreasing Circles, Cultural Dissonance, and Incongruence with Colleagues. DISCUSSION: This study highlighted both similarities and differences in moral distress than those described previously in the literature. Military unique situations contribute to the experience of moral distress in USAF CCAT nurses. These findings will guide future research aimed at understanding and mitigating moral distress effects in military nurses and other healthcare providers.

Psychometric properties of the Italian version of the Nurses' Global Assessment of Suicide Risk (NGASR) scale.

AIM: People with mental disorders have higher risk of suicide compared to the general population. Assessment of risk factors can help nurses reducing suicidal risk. The Nurses' Global Assessment of Suicide Risk scale (NGASR) has proven valid and reliable in supporting the nursing evaluation of suicidal risk in different studies. The aim of the study was to examine the psychometric properties of the NGASR in the Italian population. METHODS: We translated the scale and administered it to a sample of 121 patients admitted to acute psychiatric wards. RESULTS: The Content Validity Index-Scale (CVI-S) was 96.7%, the correlation with the Scale for Suicide Ideation (SSI) score was high (r=.98, p<.001). Inter-rater reliability (rho=.97, p<.001), and test-retest stability (p=.96) were satisfactory. Factor analysis pointed out 5 factors and the 15 items of the NGASR-ita explained 61.29% of total variance. Of the 121 subjects assessed upon admission, 25.62% had average or higher suicidal risk. DISCUSSION AND CONCLUSIONS: The use of valid screening tools in support of Suicide risk assessment is recommended. The NGASR-ita is a valid and reliable tool, suitable for nursing assessment of suicidal risk in the acute psychiatric setting.

A systematic review of clinical supervision evaluation studies in nursing.

According to the international, extant literature published during the last 20 years or so, clinical supervision (CS) in nursing is now a reasonably common phenomenon. Nevertheless, what appears to be noticeably 'thin on the ground' in this body of literature are empirical evaluations of CS, especially those pertaining to client outcomes. Accordingly, the authors undertook a systematic review of empirical evaluations of CS in nursing to determine the state of the science. Adopting the approach documented by Stroup et al. (JAMA, 283, 2000, 2008), the authors searched for reports of evaluation studies of CS in nursing - published during the years 1995 to 2015. Keywords for the search were 'clinical supervision', 'evaluation', 'efficacy', 'nursing', and combinations of these keywords. Electronic databases used were CINAHL, MEDLINE, PsychLIT, and the British Nursing Index. The research evidence from twenty-eight (28) studies reviewed is presented, outlining the main findings with an overview of each study presented. The following broad themes were identified and are each discussed in the study: narrative/anecdotal accounts of positive outcomes for clinical supervision, narrative/anecdotal accounts of negative outcomes for clinical supervision, empirical positive outcomes reported by supervisee, and empirical findings showing no effect by supervisee.

Assessment of Suicide Risk: Validation of the Nurses' Global Assessment of Suicide Risk Index for the Portuguese Population.

BACKGROUND: Mental health problems, particularly depression, are a major risk factor for suicide. Currently, there is no way to predict, with 100% accuracy, who will make a suicide attempt, but during a clinical interview, it is possible to assess the risk presented by each patient based on the investigation of risk and protective factors. The assessment of these factors helps health care professionals make decisions on the interventions to put into practice, thus contributing to reducing risk. The use of suicide risk assessment tools, properly validated for the population under consideration facilitate communication and information gathering, with clinical nurse specialists in mental health playing an important role. METHOD: Because of the shortage of suicide risk assessment tools properly validated for the Portuguese population, it was our aim to translate, adapt and validate the Nurses Global Assessment of Suicide Risk (NGASR) for the Portuguese population. In this study, a questionnaire was applied to a sample of 109 patients with depressive symptoms and risk factors for suicidal behaviors. RESULTS: The analysis of the results showed that most sample participants had a very high risk of suicide. The study of the psychometric properties of the NGASR showed moderate internal consistency and good content and criterion validity. Content validity, obtained through a panel of experts, was consensual. The NGASR index had good criterion validity, showing strong correlation with the SIQ, BDI and DASS-21 (R=0.830, p<0.05). The principal components analysis showed 6 factors, and the 15 predictive variables explained 66.92% of the total variance. CONCLUSION: These results are similar to those obtained in studies conducted in other countries and, therefore, the application of the NGASR is believed to be reliable for the Portuguese population.

Inter-rater reliability of the German version of the Nurses' Global Assessment of Suicide Risk scale.

In comparison to the general population, the suicide rates of psychiatric inpatient populations in Germany and Switzerland are very high. An important preventive contribution to the lowering of the suicide rates in mental health care is to ensure that the risk of suicide of psychiatric inpatients is assessed as accurately as possible. While risk-assessment instruments can serve an important function in determining such risk, very few have been translated to German. Therefore, in the present study, we reported on the German version of Nurses' Global Assessment of Suicide Risk (NGASR) scale. After translating the original instrument into German and pretesting the German version, we tested the inter-rater reliability of the instrument. Twelve video case studies were evaluated by 13 raters with the NGASR scale in a 'laboratory' trial. In each case, the observer's agreement was calculated for the single items, the overall scale, the risk levels, and the sum scores. The statistical data analysis was conducted with kappa and AC1 statistics for dichotomous (items, scale) scales. A high-to-very high observers' agreement (AC1: 0.62-1.00, kappa: 0.00-1.00) was determined for 16 items of the German version of the NGASR scale. We conclude that the German version of the NGASR scale is a reliable instrument for evaluating risk factors for suicide. A reliable application in the clinical practise appears to be enhanced by training in the use of the instrument and the right implementation instructions.

Unearthing the Theoretical Underpinnings of "Green Care" in Mental Health and Substance Misuse Care: Theoretical Underpinnings and Contemporary Clinical Examples.

The concept of "Green Care" can increasingly be found in mental health and addictions literature and some Psychiatric/Mental Health Nurses are practicing in facilities that base their approach on some or all of the underpinning theoretical elements of Green Care. However, Green Care is not yet widely considered to be part of mainstream psychiatry. Unearthing and articulating its theoretical underpinnings and clinical applications may further advance its legitimacy. Accordingly, this article identifies four principal theoretical elements of Green Care: Connectedness; Contact with Nature; Benefits of Exercise; and Occupation/Work as Therapeutic, each of which is explored and articulated by drawing on relevant literature.

Nursing Leadership, Missing Questions, and the Elephant(s) in the Room: Problematizing the Discourse on Nursing Leadership.

To expose inconsistencies and contradictions in the nurse leadership literature ("text"), this article adopts a deconstructive approach and draws upon the work of Derrida in examining the text or discourse. What is almost entirely missing in the literature are articles that ask difficult, searching questions that challenge some of the taken-for-granted truths or maxims about nursing leadership. The current examination of the literature, described in this article, shows: (a) a lack of convergence of the literature and health care/nursing organizations concerning leadership, (b) a conflation of nursing leadership with managerial or administrative positions, and

Raiders of the Lost Art: A review of published evaluations of inpatient mental health care experiences emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia.

Forming interpersonal therapeutic relationships with mental health Service Users remains a key aspect of the practice of Psychiatric/Mental Health nurses. Given the omnipresence of the concept within the relevant literature the reader could be forgiven for asking: why would Psychiatric/Mental Health nurses opine about something so basic, so ubiquitous and so central to the theory and practice of our discipline? While the authors could locate no substantive argument that refutes the role or value of such relationships, a sizable, growing and reasonably consistent body of work has emerged, which appears to indicate that this centrality and value is not necessarily reflected in many clinical practice settings. Accordingly, we draw on the published evaluations of mental health care emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia, compare these findings and highlight similarities or/and congruence and discuss a range of issues arising out of the findings. Alas, the findings seem to depict a mental health care inpatient experience that is often devoid of warm therapeutic relationships, respectful interactions, information or choice about treatment and any kind of formal/informal 'talk therapy'. Instead such care experiences are personified by: coercion, disinterest, inhumane practices, custodial and controlling practitioners and a gross over use of pharmacological 'treatments'.

Towards Effective Management in Psychiatric-Mental Health Nursing: The Dangers and Consequences of Micromanagement.

Micromanagement refers to a management style that involves managers exercising control over team members, teams, and also organizations, particularly in relation to the minutiae or minor details of day-to-day operations. While there is no single reason why some managers may choose to micromanage, many micromanagers exhibit similar behavioral traits, a consequence of perfectionism and/or underlying insecurities. In the culture of high performance that characterizes many contemporary mental health contexts, micromanagement also provides one way by which teams can be driven to achieve targets. However, over time, micromanagement leads to reductions in staff morale, creativity, and productivity; and increases in staff turnover. This paper provides an overview of micromanagement, including points of consideration for managers interested in reflecting on their management styles, and strategies for mental health nurses who find themselves working for a micromanager.

Mental health nurses responding to suffering in the 21st century occidental world: accompanying people in their search for meaning.

Much of contemporary health and mental health practice pays little attention to suffering, and when it does, invariably suffering is conflated with pain. Within such views, the health care practitioner ought to be concerned with removing or stopping the suffering as, for many parts of the occidental world at least, suffering is regarded as antagonistic to the pursuit of happiness. However, it has been recognized since ancient times that the experience of suffering can give rise to growth. This view sees suffering as an inevitable aspect of the human condition and experience; as something that might need to be endured, minimized, relieved, explored for meaning and maybe even learned from. The former conceptualization of suffering leaves little, if any, room for the sufferer to be to be proud of his suffering and to consider it ennobling rather than degrading, and such views are highly congruent with the increased pathologizing of 'everyday life' and with that, the inexorable proliferation of pharmacological 'treatment'. Accordingly, we assert that there is a clear need for Psychiatric/Mental Health nurses to re-think their views of suffering and consider how they might help the person discover meaning in the experience; how they might accompany the individual on his/her suffering journey. We therefore identify a range of approaches and interventions that Psychiatric/Mental Health nurses can use when attempting to help those experiencing mental health-related suffering.

Shadows from the past: the situated meaning of being suicidal among depressed older people living in the community.

BACKGROUND: Most depressed older people in a suicidal state have mixed feelings, where the wish to live and the wish to die wage a battle. AIMS: To explore and describe depressed older people's experiences of being suicidal and their search for meaning. METHOD: Data were collected from 29 participants resident in the Rogaland and Vestfold districts of Norway, by means of individual interviews, after which a thematic analysis was performed. RESULTS: For the participants in this study, the lived experiences of the situated meaning of survival after being suicidal comprised a main theme - "shadows from the past" - and two themes - "feeling that something inside is broken" and "a struggle to catch the light." CONCLUSION: Mental health-care professionals might be able to reduce the risk of suicide and perturbation by helping depressed older people to explore, resolve, and ultimately come to terms with their unresolved historical issues. Additional valuable strategies in primary care settings include encountering patients frequently, monitoring adherence to care plans, and providing support to address the source of emotional pain and distress.

The effects of suicide ideation assessments on urges to self-harm and suicide.

BACKGROUND: Participants' safety is the primary concern when conducting research with suicidal or potentially suicidal participants. The presence of suicide risk is often an exclusion criterion for research participants. Subsequently, few studies have examined the effects of research assessments on study participants' suicidality. AIMS: The purpose of this research was to examine the patterns of postassessment changes in self-harm and suicide urges of study participants who were recently discharged from an inpatient psychiatric service. METHOD: Study participants (N = 120) were recruited from patients with a lifetime history of suicidal behavior admitted with current suicidal ideation or suicide attempt to an inpatient psychiatric service and/or a crisis stabilization unit. Participants were assessed for suicidal ideation with the Suicide Ideation Scale at 1, 3, and 6 months following their discharge from hospital. The risk assessment protocol was administered at the start and at the end of each of the study follow-up assessments. RESULTS: Changes in self-harm and suicide urges following study assessments were small, infrequent, and were most likely to reflect a decrease in suicidality. Similarly, participants rarely reported worsening self-control over suicidal urges, and when they did, the effect was minimal. By the end of the 6-month follow-up period, increases in self-harm and suicidal urges postassessment were not seen. CONCLUSION: The inclusion of suicidal participants in research interviews rarely increased suicide risk. Research involving suicidal individuals is possible when study protocols are well planned and executed by trained assessors and clinicians who are able to identify participants at risk and provide intervention if necessary. The few participants that required intervention had high levels of suicide ideation and behavior at baseline and almost all reported symptoms of posttraumatic stress disorder. Further study is needed to better characterize this subgroup of participants.

Systemic perspective of violence and aggression in mental health care: towards a more comprehensive understanding and conceptualization: part 2.

This is the second of a two part paper which seeks to explore a wide range of phenomena that have been found to have an association with aggression and violence (A/V) in inpatient mental health care, synthesize these propositions according to fit or congruence into a systemic model of A/V, explore the empirical evidence pertaining to these propositions, and begin to consider application of this model to better inform our individual and/or organizational responses to A/V in mental health care. The systemic model is comprised of four thematic categories with part two of the paper focusing on the final two categories: mental health-care system-related phenomena and clinician-related phenomena. The paper then discusses a number of implications arising out of embracing a more systemic model of A/V in mental health care. In broadening our understanding to include all the phenomena that contribute increased risk of A/V incidents, we are able to move away from inaccurate views that disproportionately assign 'responsibility' to clients for causing A/V when the evidence indicates that the client-related phenomena may only account for a small portion of these incidents.

Systemic perspective of violence and aggression in mental health care: towards a more comprehensive understanding and conceptualization: part 1.

Aggression and violence (A/V) in mental health care are all too frequent occurrences; they produce a wide range of deleterious impacts on the individual client, staff, organizations, and the broader community. A/V is a multifaceted and highly-complex problem, and is associated empirically with a wide range of phenomena. However, most attempts to reduce A/V in mental health care have invariably focused on one or two aspects of the problem at the expense of a more comprehensive, systemic approach; these have produced inconclusive results. As a result, this two-part paper seeks to: (i) recognize the wide range of phenomena that have been found to have an association with A/V in mental health care; (ii) synthesize these propositions according to fit or congruence into a systemic model of A/V; (iii) explore empirical evidence pertaining to these propositions; and (iv) begin to consider the application of this model to better inform our individual and/or organizational responses to A/V in mental health care. The paper advances a systemic model of these phenomena comprised of four thematic categories, with Part 1 of this paper focusing on the first two categories: environmental and intrapersonal (client-related) phenomena.