Psychiatrists' attitudes to professional boundaries concerning spirituality and religion: mixed-methods study.

AIMS AND METHOD: Calls for the integration of spirituality into psychiatric practice have raised concerns about boundary violations. We sought to develop a method to capture psychiatrists' attitudes to professional boundaries and spirituality, explore consensus and understand what factors are considered. Case vignettes were developed, tested and refined. Three vignettes were presented to 80 mental health professionals (53% said they were psychiatrists; 39% did not identify their professional status). Participants recorded their reactions to the vignettes. Four researchers categorised these as identifying boundary violations or not and analysed the factors considered. RESULTS: In 90% of cases, at least three of the four researchers agreed on classification (boundary violation; possible boundary violation; no boundary violation). Participants' opinion about boundary violations was heterogeneous. There was consensus that psychiatrists should not proselytise in clinical settings. Reasoning emphasised pragmatic concerns. Few participants mentioned their religious beliefs. Equivocation was common. CLINICAL IMPLICATIONS: Mental health professionals seem unsure about professional boundaries concerning religion and spirituality in psychiatric practice.

Breaking out of the citadel: social theory and psychiatry.

British psychiatry has tended to hold itself aloof from social theory. Nonetheless, these ideas have influenced the development of mental health services. Alongside this, the biopsychosocial model cannot reconcile contradictions in the scientific evidence regarding mental illness. We need to develop a more constructive understanding of the implications of social theory.

The effect of the COVID-19 pandemic on mental health in individuals with pre-existing mental illness.

BACKGROUND: There is evidence that the COVID-19 pandemic has negatively affected mental health, but most studies have been conducted in the general population. AIMS: To identify factors associated with mental health during the COVID-19 pandemic in individuals with pre-existing mental illness. METHOD: Participants (N = 2869, 78% women, ages 18-94 years) from a UK cohort (the National Centre for Mental Health) with a history of mental illness completed a cross-sectional online survey in June to August 2020. Mental health assessments were the GAD-7 (anxiety), PHQ-9 (depression) and WHO-5 (well-being) questionnaires, and a self-report question on whether their mental health had changed during the pandemic. Regressions examined associations between mental health outcomes and hypothesised risk factors. Secondary analyses examined associations between specific mental health diagnoses and mental health. RESULTS: A total of 60% of participants reported that mental health had worsened during the pandemic. Younger age, difficulty accessing mental health services, low income, income affected by COVID-19, worry about COVID-19, reduced sleep and increased alcohol/drug use were associated with increased depression and anxiety symptoms and reduced well-being. Feeling socially supported by friends/family/services was associated with better mental health and well-being. Participants with a history of anxiety, depression, post-traumatic stress disorder or eating disorder were more likely to report that mental health had worsened during the pandemic than individuals without a history of these diagnoses. CONCLUSIONS: We identified factors associated with worse mental health during the COVID-19 pandemic in individuals with pre-existing mental illness, in addition to specific groups potentially at elevated risk of poor mental health during the pandemic.

A study of the implementation of patient safety policies in the NHS in England since 2000: what can we learn?

PURPOSE: Despite repeated policy initiatives, progress in improving patient safety in the National Health Service (NHS) in England over the past two decades has been slow. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019), which is being implemented currently, aims to address this problem. The purpose of this study is to identify learning from the implementation of past patient safety policies and thereby suggest means of supporting the NHS in delivering the current policy initiative successfully. DESIGN/METHODOLOGY/APPROACH: The authors identified key health policies in the domain of patient safety, published since 2000, by searching the United Kingdom (UK) government website. Discussion papers from the research literature concerning these policies were collated and reviewed. The authors then used a thematic analysis approach to identify themes discussed within these papers. These themes represent factors that support the effective delivery of patient safety policy initiatives. FINDINGS: Within the discussion papers the authors collated, concerning 11 patient safety policies implemented between 2000 and 2017, five inter-related core themes of capability, culture, systems, candour and leadership were identified. By evaluating these themes and identifying composite sub-themes, a conceptual framework is presented that can be used to support the delivery of patient safety policy initiatives to maximise their impact. ORIGINALITY/VALUE: The conceptual framework the authors illustrate, arising from this new contribution to the body of knowledge, can be translated into a novel self-assessment for individual NHS trusts to understand organisational development areas in the domain of patient safety improvement.

Exploration of joint working practices on anti-social behaviour between criminal justice, mental health and social care agencies: A qualitative study.

Although the police play an important role for people with mental health problems in the community, little is known about joint working practices between mental health, social care and police services. There is potential for tensions and negative outcomes for people with mental health problems, in particular when the focus is on behaviours that could be interpreted as anti-social. This study explores perceptions about joint working between mental health, social care and police services with regard to anti-social behaviour. We conducted a multi-method sequential qualitative study in the UK collecting data between April 2014 and August 2016. Data were collected from two study sites: 60 narrative police logs of routinely gathered information, and semi-structured interviews and focus groups with professionals from a range of statutory and third sector organisations (N = 55). Data sets were analysed individually, using thematic iterative coding before integrating the findings. We also looked at sequencing and turning points in the police logs. Findings mapped on a continuum of joint working practices, with examples more likely to be away from the policy ideal of partnership working as being central to mainstream activities. Joint working was driven by legal obligations and concerns about risk rather than a focus on the needs of a person with mental health problems. This was complicated by different perceptions of the police role in mental health. Adding anti-social behaviour to this mix intensified challenges as conceptualisation of the nature of the problem and agreeing on best practice and care is open to interpretations and judgements. Of concern is an evident lack of awareness of these issues. There is a need to reflect on joint working practices, including processes and goals, keeping in mind the health and welfare needs of people with mental health problems.

An assessment of need for mental health rehabilitation amongst in-patients in a Welsh region.

BACKGROUND: Rehabilitation services have received little attention in the literature compared with other types of mental health service provision over the past 15 years. However, they are an important component of whole-system functioning in mental health services. Lack of provision has a particular impact on acute in-patient services. Poor pathway management can result in delayed discharges, placement of service users far from home, and resultant loss of resource for the local mental health economy. METHODS: A cross-sectional study gathered demographic, clinical, service utilisation, and financial data on 100 participants from out of area, rehabilitation and acute mental health units. Financial data was provided by the Health Board. Other data were gathered by two clinicians from case records and staff interviews. FINDINGS: 26.0 % of people were inappropriately placed, with frequent overprovision of support. It was calculated that within an annual budget of £12.7 M, £2.5 M (19.7 % of the total expenditure on this patient group) could be saved if all placements were appropriate. INTERPRETATION: There were differences between the three cohorts. Those placed out of area had the most complex needs, although those in rehabilitation placements were similar. Most participants had been in contact with services for more than 5 years. A system better matched to their needs would benefit these patients and would also generate financial savings for reinvestment in the mental health economy.

Profile: Vanessa Cameron - 36 years at the Royal College of Psychiatrists.

On 16 December 2016, Vanessa Cameron retires as Chief Executive of the Royal College of Psychiatrists. She started working there in September 1980 and in 1984 she became Secretary of the College, the role that preceded chief executive. The College was formed in 1971, so Vanessa has been present for most of its lifetime. It has been a period of continuous change that has seen psychiatry leave the old mental hospitals, expand considerably in the late 1990s and early part of the 21st century, and come under huge pressure more recently. Although she has never worked within mental health services, Vanessa has been at the heart of British psychiatry for 36 years. She was awarded an MBE in the 2013 New Year's Honours list for services to psychiatry. We interviewed Vanessa at 21 Prescot Street on 3 August 2016.

The influence of child sexual abuse on the self from adult narrative perspectives.

The impact of child sexual abuse on the adult self is not yet clearly understood. We explored adult perspectives through the use of narrative interviews (N = 30). Three key themes or views of self were identified in all narratives to varying degrees: the worthless self, the self as unknown, and the potential/developing self. Ambivalence and tension were present in all narratives. Individuals were challenged to integrate the sexual abuse experience in a constructive way and develop a more coherent perception of the self. The narrative method highlighted the dynamic nature of peoples' experiences at the same time recognizing that the narratives themselves are in progress. Reactions to disclosure, social support, and interpersonal connections are crucial at every turn.

Does coping mediate the relationship between familism and caregiver outcomes?

OBJECTIVES: The sociocultural model of stress and coping, which despite receiving support from several studies conducted with diverse ethnic groups, has yet to be tested longitudinally or used within the context of positive caregiver outcomes. The aim of the current study was to test a specific component of the model, which posits that caregiver coping will be influenced by the cultural value of familism (feelings of solidarity and loyalty among family members), which will in turn affect caregiver outcomes. METHOD: A questionnaire was completed by 123 family caregivers in the UK assessing familism, use of coping strategies, caregiver gains, anxiety and depression at three time points over nine months. RESULTS: Mediation analysis followed guidelines proposed by Baron and Kenny. Religious coping and positive reframing at time 2 (T2) were found to significantly mediate between familism values at time 1 (T1) and caregiver gains at time 3 (T3). Behavioural disengagement at T2 was found to mediate between familism at T1 and caregiver depression at T3. Additionally familism was found to be positively associated with both negative and positive aspects of caregiving. CONCLUSION: Our longitudinal findings suggest that interventions and services acknowledging caregiver values and the associated coping responses may prove beneficial.

Exploring caregiving experiences: caregiver coping and making sense of illness.

OBJECTIVES: The current research explores how family caregivers (1) make sense of caregiving and (2) cope with their circumstance. METHOD: We analysed semistructured interviews of 13 caregivers of people with either stroke (n = 5) or dementia (n = 8) and used photographs that caregivers took exemplifying their caregiving experiences to elicit their description of how they made sense of caregiving. This enabled greater insight into caregivers' perspective of caregiving complementing our use of Interpretative Phenomenological Analysis (IPA) to analyse verbatim transcripts. RESULTS: Emerging themes included (1) making sense of illness including the implications of receiving a diagnosis, caregiving motivations and receiving support, and (2) coping with caregiving, with variance in coping depending on, in part, individual differences in sense making. Caregivers adopted active and information seeking techniques to deal with current problems and to increase their sense of control, but avoidant techniques when considering future logistics of caregiving and when feeling helpless due to the burden they faced. At times caregivers looked on the bright side and made downward comparisons. CONCLUSION: The combination of elicitation techniques and analysis using IPA established patterns across caregivers and individual differences between caregivers in the meaning they assigned to their caregiving experience. Differences in sense making were based on the context of the caregiving stressor, which in turn influenced the variability in caregiver's coping techniques adopted. The analysis detailed within this article provides evidence that information and service provision must be tailored to individual caregiver experiences.

Ethnicity, familism and willingness to care: important influences on caregiver mood?

OBJECTIVE: Few studies have to date examined the effects of ethnicity on caregiver motivations, coping responses and mood. This theoretically informed study uses the socio-cultural model of stress and coping to explore these relationships amongst a White-British and British South-Asian caregiver sample. METHOD: A total of 235 primary family caregivers were recruited for a cross-sectional questionnaire survey; of which 162 were White-British and 73 were British South-Asian. RESULTS: British South-Asian caregivers differed from White-British caregivers on several variables within the stress-coping framework. British South-Asian caregivers were younger, had significantly higher levels of familism, used significantly more behavioural disengagement and religious coping and reported having significantly less support than White-British caregivers. White-British caregivers were more likely to make use of substances and humour as coping methods, and also in these caregivers, familism was significantly related to caregiver depression. Whilst levels of willingness to care did not differ between the two caregiver groups, opposing relationships were seen in the association between willingness to care and caregiver anxiety. Regression analyses found that self-blame explained a significant proportion of variance in South-Asian anxiety and depression, whereas depression amongst White-British caregivers was associated with high use of substances, low use of humour and low mean satisfaction with support. CONCLUSION: These findings offer support to the socio-cultural model of stress and coping in that coping is associated with two outcomes (anxiety and depression), but motivational factors are also highlighted which have additional implications for the development of culturally specific interventions aimed at reducing caregiver distress.

Compulsory medical rural placements: senior student opinions of early-year experiential learning.

OBJECTIVE: The aim of this study was to determine senior medical student (year 3-5) opinions of their early-year (year 1-2) rural placement. DESIGN: We assessed the impact of MBBS early-year rural placements through a follow up of this cohort in their later years using a cross-sectional questionnaire. SETTING: The questionnaire was administered to year 3-5 medical students at their clinical school. PARTICIPANTS: There were 97 participants (49% response rate) in the study. Twenty-nine per cent were male and 71% were female; 44% were from a rural background and 56% were from a metropolitan background; 48% were year 3 students, 32% were year 4 students and 20% were year 5 students; and 59% of the students were, at the time, situated at a rural clinical school and 41% were at a metropolitan clinical school. MAIN OUTCOME MEASURE: Closed-ended questions were quantified and statistically analysed. Open-ended responses were thematically analysed to determine what their experience of early-year rural placements were like. RESULTS: Seventy-nine per cent of students considered the year 1 placement length as 'about right'. Overall, most students found year 1 rural placements positive and grasped the placement aims and objectives. Most students were also pleased with year 2 rural placements, mainly due to the clinical aspects. CONCLUSIONS: Medical students appear to prefer shorter early-year rural placements and understand the benefits and importance of such placements. They also have a desire for greater clinical exposure during these early-year placements.

Ethnic variations in the caregiver role: a qualitative study.

The present study aimed to establish an in-depth qualitative analysis of the convergence and divergence of the experiences of caregivers from four ethnic groups. Eight Bangladeshi, nine Indian, four Pakistani and nine White-British caregivers participated in five focus groups. Differences and similarities between motivations for role adoption, willingness to care, experience of role, adaptation to role, coping, use of and satisfaction with support were discussed. Key differences were found in adaptation to care role and use of social support. The article highlights the need for further study of the ethnic minority caregiver experience and has implications for service development.

Carers with chronic conditions: changes over time in their physical health.

OBJECTIVES: To explore the experiences of individuals with chronic conditions who are also caring for another person, usually a family member. METHOD: A postal questionnaire was distributed to carers across Wales on three occasions approximately 18 months apart. It included the SF-12v2 together with fixed-choice and open-ended questions relating to carer demographics, carer assessment, support needs, services received and care recipient's medical condition. A sub-sample of these carers was invited to take part in face-to-face interviews to allow for more in-depth exploration of their circumstances. RESULTS: The carers with chronic conditions experienced a decline in their physical health over time whereas the physical health of carers without a chronic condition remained stable. There was also evidence of carers neglecting their own health because of their caring responsibilities. Despite their health problems, over time the carers with chronic conditions received no more support than other carers. DISCUSSION: This article indicates that there are carers who are themselves suffering from a physical condition or conditions that suggest they are in need of care. Despite these difficulties, these carers are caring for people with quite severe conditions, without any help above that available to other carers.

An emotive subject: insights from social, voluntary and healthcare professionals into the feelings of family carers for people with mental health problems.

Caring for people with mental health problems can generate a whole range of positive and negative emotions, including fear, disbelief, guilt and chaos as well as a sense of purpose, pride and achievement. This paper explores the emotions of family carers from the perspectives of social, voluntary and healthcare professionals. Sixty-five participants were interviewed, the sample included directors, managers and senior staff from social, voluntary and healthcare organisations. Participants were encouraged to talk in detail about their understanding of the emotions of family carers. Findings highlight a rich understanding of the broad spectrum of carer emotions and the huge emotional adjustments that are often involved. Diagnosis was seen to be imbued with negative emotions, such as fear, anger and denial. However, feelings of hopelessness and desolation were often counterbalanced by feelings of hope, satisfaction and the emotional rewards of caring for a loved one. Participants noted a clear lack of emotional support for family carers, with accompanying feelings of marginalisation, particularly during transitions and especially involving young carers as well as ethnic minorities. By way of contrast, carer support groups were suggested by professionals to be a holistic, effective and economical way of meeting carers' emotional needs. This paper explores the challenge of family carer emotions from the perspective of managers and practitioners and draws out implications for research, policy and practice.

Stress and job satisfaction among social workers, community nurses and community psychiatric nurses: implications for the care management model.

The introduction in April 1993 of new arrangements for assessment and care management following the NHS and Community Care Act 1990 (Department of Health 1990a) heralded a period of major transition for front-line workers in the health and social services. Policy expectations for the development of the purchaser/provider split and the 'new managerialism' have posed unprecedented ideological, organizational and professional challenges. Two years after the full implementation of the reforms a postal survey of the experiences of care managers about policy and practice changes was undertaken in Wales. This paper focuses on the stresses and satisfactions of care management practice among three distinct groups of front-line workers: social workers, community nurses and community psychiatric nurses. The results of multiple regression analyses, corroborated by qualitative data, implicate an increased workload in general and administrative work in particular, combined with reduced opportunities for client contact, as the main sources of stress. Being able to control or shape those factors impinging on the experience of stress and job satisfaction appears to lie at the heart of the dilemma. Practice and policy implications are considered.