Defensive practices in mental health nursing: Professionalism and poignant tensions.

Mental health nursing is a skilled profession, well positioned to support patients towards recovery with evidence-based therapeutic interventions. However, the profession continues to be challenged by tensions surrounding the delivery of restrictive interventions and concerns over tendencies towards defensive practices. This paper examines the ambiguity this creates within the mental health nursing role. Organizational cultures that overvalue metrics and administrative tasks create barriers for therapeutic engagement while contributing to role confusion and stress within nursing. We need to address such structural constraints on nurses as mental health nurses' well-being is crucial to service delivery and the realization of therapeutic goals. From the UK perspective, authors argue that there is a need to examine service structures that foster compassionate and transformational leadership to enable mental health nurses to exercise the agency to practice therapeutically. Education and quality nursing research have a pivotal role to play in enabling this shift.

Shared learning to improve the care for young people and mental health within nurse education (SHYNE). Improving attitudes, confidence and self-efficacy.

Preparing students for the complexities of practice is an ongoing challenge of pre-registration nurse education. One such complexity is the increase in children and young people with mental health problems. Pre-registration student nurses from child and mental health specialisms from one University participated in an innovative simulation session, whereby actors from a youth theatre group simulated young people admitted to an acute non-mental health hospital setting for treatment of self-harm injuries. This study used an uncontrolled pre and post design to determine the impact of the session on student nurses' attitudes, confidence and self-efficacy when caring for young people who self-harm. Attitudes towards self-harm was measured using a 13 item self-report questionnaire. Confidence was measured through Likert scale responses. Self-efficacy for working with children and young people who have self-harmed was measured through an adapted version of the Self-Efficacy Towards Helping (SETH) scale. In total 101 student nurses took part in the study and 99% completed post simulation outcome measures. At post-session, the students reported a statistically significant improvement in attitudes, self-efficacy and confidence towards children and young people who self-harm. A lack of confidence is frequently reported in the literature when caring for this client group in practice settings. Improvements in attitudes, confidence and self-efficacy can positively impact individual nursing practice. Furthermore the simulation literature indicates that the skills consolidated using such an educational approach are taken forward into clinical practice. While broad claims of success should be avoided, it is promising to find a learning method that is effective in addressing a contemporary and complex health issue. Shared Learning to Improve the Care for Young People and Mental Health within Nurse Education (SHYNE): Improving Attitudes, Confidence and Self-Efficacy.

Exploring young people's experiences and perceptions of mental health and well-being using photography.

INTRODUCTION: The mental health of young people is a major global public health concern. A shift in focus towards children and young people's mental health in the UK has emphasized young people's voices, as of paramount importance in shaping the path for future quality care provision. The paper examines a study that aimed to explore young people's perceptions of mental health and well-being using photographs. METHOD: The methodology employed for this study placed young people at the centre of the research process by using photographs to capture their experiences. Ten young people who attended a youth group used disposable cameras to take photographs of their experiences and perceptions of mental health and well-being. Semi-structured interviews with the young people elicited their narratives behind the images. Data were analysed using photo-elicitation and thematic analysis. FINDINGS: Young people's experiences of mental health and well-being were internalized and located predominantly in the private and hidden regions of their everyday lives. Stigma, social isolation and marginalization were prevalent whilst spirituality and connection with the environment expressed hope. CONCLUSION: Mental health appears to be firmly located in the private 'back regions' of young individuals' lives, demonstrating that young people conceptualize these experiences as a vulnerable and hidden part of their being. Understanding the needs of this new generation of youth including the prevalence of stigma, risk of isolation and social exclusion are paramount. Future service provision needs to recognize the extent stigma impacts upon young people's experiences of mental health and well-being.

The construction of people with mental health problems as risk objects: Findings of a case study inquiry.

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self-determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users' subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. ABSTRACT: Introduction The emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. Aim To explore how practitioners, experience potential tensions arising from delivering recovery-orientated care and enforcing containment. Method This paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. Results Risk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. Discussion Hilgartner's (1992, Organizations, uncertainties and risk (pp. 39-53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practice To undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.

Evaluating a co-facilitation approach to service user and carer involvement in undergraduate nurse education.

Partnership working with service users and carers is an integral aspect of healthcare practice and education. Increasingly complex healthcare environments, alongside changes in higher education, have led to the development of innovative learning strategies, resulting in opportunities for service users to participate in nurse education. This article describes the planning, implementation and evaluation of a co-facilitation approach to learning, in which service users and carers worked alongside lecturers to facilitate small seminar group activities with first-year undergraduate nursing students. AIM: To evaluate the effects of a co-facilitation approach on nursing students' classroom learning. In this approach, service users and carers co-facilitated small seminar group activities with lecturers. METHOD: The co-facilitation approach was introduced concurrently in 14 groups of first-year nursing students across adult, child, mental health and learning disabilities fields of nursing in one higher education institution. The approach was evaluated using a questionnaire comprised of open-ended questions, which was distributed to the nursing students after they had participated in the facilitated group sessions. FINDINGS: A total of 198 nursing students completed the questionnaire. Their feedback was positive, indicating that they found the participation of service users and carers in the facilitation of group activities a stimulating and inspiring way to learn, and it improved their understanding of person-centred approaches to care. CONCLUSION: The involvement of service users and carers in classroom learning is meaningful and relevant to nursing students' education. The co-facilitation approach enabled them to understand the person rather than only the patient, which is essential in providing person-centred care. However, it is necessary to identify the means to support students to build resilience and maintain their learning in challenging healthcare environments.

Therapeutic relationships, risk, and mental health practice.

Despite significant changes to mental health services, nurses remain the professional group most likely to be in close contact with people who experience mental health problems. A core part of the contemporary identity of the mental health nurse is one who is able to provide acceptance and support for an individual's recovery through the therapeutic relationship. Yet there have always been some tensions with the mental health nursing role that can appear to challenge this relational focus. An increasing prominence of risk management in mental health care can position mental health nurses as responsible for enacting restrictions and has reignited interest in the role of mental health professionals in social control. This paper reports on one part of a multiple case study, which aimed to explore mental health professionals' experiences of such tensions in the context of decision-making. Interviews and observations were undertaken in acute ward and assertive outreach settings. Findings suggested that risk dominated decision-making to such an extent it defined the way service users were understood and treated. A distant relationship between professionals and service users helped to create and maintain this situation. There needs to be a greater focus on service users' subjective experiences in the decision-making process to challenge the definition of people with mental health problems as risky.

Simulation in mental health nurse education: The development, implementation and evaluation of an educational innovation.

Simulation is an important learning approach for the development of skills for healthcare practice. However, it remains under used in the education of mental health practitioners. This article examines the development, implementation and evaluation of a simulated learning experience for final year undergraduate BSc mental health nursing students in the UK. Scenarios involving managing care in an acute in patient ward and community older persons' team were designed to enable students to develop their complex decision making skills. An evaluation of the simulation experience was undertaken. This was informed by the principles of improvement science methodology and data was collected from the student participants using questionnaires. The findings indicated that simulation provided a realistic environment in which students were able to develop skills and manage clinical situations autonomously without fear of being assessed or making mistakes. Reflecting Dieckmann et al.'s (2007) position that simulation is a social situation in itself, the learning approach enabled mental health students to both experience the safety of the Higher Education setting and also the reality of clinical practice. Simulation may therefore provide an important tool to prepare students for the responsibilities of a qualified nurse.

Treatment urgency: The importance of getting people with type 2 diabetes to target promptly.

The burgeoning population of individuals with type 2 diabetes provides challenges for management in terms of risk of diabetes-related complications. Early, intensive glycemic control particularly in newly-diagnosed people with type 2 diabetes has been shown to be beneficial in terms of reducing diabetic complications, indeed various national and international guidelines now routinely recommend intensive blood glucose control as an essential element of type 2 diabetes management. However, despite this, current management of glycemia is suboptimal and not enough people achieve their glucose targets worldwide. The Global Partnership for Effective Diabetes Management believe that an improved understanding of these contributing factors should enable the development of practice and guidance that will promote a drive toward better quality clinical outcomes.

A critical narrative analysis of shared decision-making in acute inpatient mental health care.

Shared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients' care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.

Developing a structured approach to safeguarding education.

Safeguarding vulnerable adults and children is a legal requirement and is essential in nursing and healthcare practice. This article describes the development and establishment of a structured approach to safeguarding education and student support in one pre-registration nursing programme in the UK. This approach involved the development of an academic safeguarding lead role, extensive curriculum development, and implementation of policies and procedures for raising and escalating concerns. The authors suggest that this integrative and comprehensive model should be used in all higher education institutions providing nurse education.

Student life--the heart of learning.

The University of Nottingham introduced a new undergraduate nursing degree programme in 2012 that aims to develop nurses who are resilient, innovative, able to empower service users and provide compassionate care.

Skills for nursing practice: development of clinical skills in pre-registration nurse education.

Rapid changes during the past two decades have seen a growing challenge to prepare newly qualified nurses who are clinically competent and confident to meet the demands of contemporary healthcare. Recent publications emphasise the need to prioritise clinical skills in nurse education (DH 2012a, Francis, 2012). This discussion reports on a project scoping the clinical skills required within pre-registration nursing curricula and considers how this has influenced curriculum development at one Higher Education Institution in the UK. This paper reports on the project analysis of nursing and healthcare policy, identifying six core themes of skills relevant for nursing practice. Furthermore it explores the findings of a series of focus groups with nursing practitioners and managers identifying priorities for clinical skills in the pre-registration curriculum. These highlighted a broad range of skills required of newly qualified practitioners, which pose a challenge for integration within nurse education. How this challenge has been addressed through the incorporation of these skills themes throughout a new pre-registration curriculum is also examined.

The role of self-monitoring of blood glucose in patients treated with SGLT-2 inhibitors: a European expert recommendation.

The role for the novel treatment approach of sodium-glucose cotransporter-2 (SGLT-2) in type 2 diabetes is increasing. Structured self-monitoring of blood glucose (SMBG), based on a less intensive and a more intensive scheme, may contribute to an optimization of SGLT-2 inhibitor based treatment. The current expert recommendation suggests individualized approaches of SMBG, using simple and clinically applicable schemes. Potential benefits of SMBG in SGLT-2 inhibitor based treatment approaches are early assessment of treatment success or failure, timely modification of treatment, detection of hypoglycemic episodes, assessment of glucose excursions, and support of diabetes management and education. The length and frequency of SMBG should depend on the clinical setting and the quality of metabolic control.

Simulation: a shared learning experience for child and mental health pre-registration nursing students.

Learning through the use of simulation is perceived as an innovative means to help manage some of the contemporary challenges for pre-registration nurse education. Mental health and child nurses need to have the knowledge and skills to effectively address the holistic needs of service users. This article reports on a pilot simulated learning experience that was designed with key stakeholders for pre-registration child and mental health nursing students. This involved young actors playing the role of someone who had self-harmed to help students develop their skills for working with young people who experience emotional distress. Focus groups and a questionnaire were used to evaluate the pilot. Students valued the practical approach that simulation entailed and identified the benefits of the shared learning experience across the different fields of practice of nursing. However, some students reported anxiety performing in front of peers and indicated they would perform differently in practice. The pilot identified simulation as a potentially useful approach to help child and mental health student nurses develop skills for caring for young people. However, there is a need for caution in the claims to be made regarding the impact of simulation to address gaps in nursing skills.

Self-monitoring of blood glucose in type 2 diabetes: recent studies.

The increasing role for structured and personalized self-monitoring of blood glucose (SMBG) in management of type 2 diabetes has been underlined by randomized and prospective clinical trials. These include Structured Testing Program (or STeP), St. Carlos, Role of Self-Monitoring of Blood Glucose and Intensive Education in Patients with Type 2 Diabetes Not Receiving Insulin, and Retrolective Study Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes (or ROSSO)-in-praxi follow-up. The evidence for the benefit of SMBG both in insulin-treated and non-insulin-treated patients with diabetes is also supported by published reviews, meta-analyses, and guidelines. A Cochrane review reported an overall effect of SMBG on glycemic control up to 6 months after initiation, which was considered to subside after 12 months. Particularly, the 12-month analysis has been criticized for the inclusion of a small number of studies and the conclusions drawn. The aim of this article is to review key publications on SMBG and also to put them into perspective with regard to results of the Cochrane review and current aspects of diabetes management.

The role of self-monitoring of blood glucose in glucagon-like peptide-1-based treatment approaches: a European expert recommendation.

The role of glucagon-like peptide (GLP)-1-based treatment approaches for type 2 diabetes mellitus (T2DM) is increasing. Although self-monitoring of blood glucose (SMBG) has been performed in numerous studies on GLP-1 analogs and dipeptidyl peptidase-4 inhibitors, the potential role of SMBG in GLP-1-based treatment strategies has not been elaborated. The expert recommendation suggests individualized SMBG strategies in GLP-1-based treatment approaches and suggests simple and clinically applicable SMBG schemes. Potential benefits of SMBG in GLP-1-based treatment approaches are early assessment of treatment success or failure, timely modification of treatment, detection of hypoglycemic episodes, assessment of glucose excursions, and support of diabetes management and diabetes education. Its length and frequency should depend on the clinical setting and the quality of metabolic control. It is considered to play an important role for the optimization of diabetes management in T2DM patients treated with GLP-1-based approaches.

Exposing the tensions of implementing supervision in pre-registration nurse education.

This discussion will examine the complexities of implementing group clinical supervision in pre-registration nurse education. Exploration is based upon the authors' experiences of facilitating clinical supervision with mental health branch students on the Diploma/BSc program at one higher education institution in the UK. It will provide the history and context of clinical supervision in nursing and apply this to the educational setting. This discussion aims to move beyond the rhetoric surrounding clinical supervision to expose the underlying tensions which we propose influence the clinical supervision process in pre-registration nurse education. These include the potential confusion of role for the supervisor, conflict of responsibilities and the potentially vulnerable position they may adopt. However, despite these tensions it is proposed that clinical supervision has a key role within graduate pre-registration nursing education.