Towards a model for understanding the development of post-traumatic stress and general distress in mental health nurses.

In their daily work, mental health nurses (MHN) are often exposed to stressful events, including patient-perpetrated aggression and violence. Personal safety and health concerns, as well as concern for the physical and psychological well-being of patients, dominate; these concerns have a profound impact on nurses. This cross-sectional study explored and compared the psychological well-being of 196 hospital-based MHN (97 forensic and 99 mainstream registered psychiatric nurses or psychiatric state enrolled nurses). The aim was to examine exposure to inpatient aggression and work stress, and identify factors contributing to the development of post-traumatic stress reactions and general distress. Multiple regression analyses indicated that working in a mainstream setting is associated with increased work stress; however, mainstream and forensic nurses experienced similar psychological well-being. As a group, 14-17% of mainstream and forensic nurses met the diagnostic criteria for post-traumatic stress disorder, and 36% scored above the threshold for psychiatric caseness. A tentative model of post-traumatic stress and general distress in nurses was developed, illustrating the impact of aggression and stress on well-being. The present study affirms that mental health nursing is a challenging and stressful occupation. Implications for organizations, managers, and individual nurses are discussed.

Police officers' views of absconding from mental health units in Victoria, Australia.

Patients regularly abscond from mental health units and at times the consequences for patients and for others can be serious. The police are involved with absconding events, but are rarely considered in the mental health literature. In most jurisdictions, the police can take missing person reports for involuntary patients whose whereabouts are unknown and there are genuine concerns for their safety or welfare. Those people remain active cases for the police until located. This paper presents extracts of 25 police officers' narratives from a qualitative research project. Officers viewed absconding as a regular event, and workload burden that was exacerbated when mental health staff rarely initiated any search for the absconded patient and abdicated responsibility too quickly to the police. The officers were concerned about communication with mental health services and reported that information about the absconded patient could be inadequate or not given to police, and police often were not informed when the patient was found or discharged. Improved liaison and cooperative working that promote effective communication could strengthen police and mental health nursing collaboration and ensure better outcomes for patients.

Exploring nurses' and patients' perspectives of limit setting in a forensic mental health setting.

Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced); and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting.

Standards of practice for forensic mental health nurses--identifying contemporary practice.

Forensic mental health nursing is a recognized field of nursing in most countries. Despite a growing body of literature describing aspects of practice, no publication has been found that captures the core knowledge, skills, and attitudes of forensic mental health nurses. One group of nurses in Australia have pooled their knowledge of relevant literature and their own clinical experience and have written standards of practice for forensic mental health nursing. This paper identifies the need for standards, provides a summary of the standards of practice for forensic mental health nurses, and concludes with how these standards can be used and can articulate to others the desired and achievable level of performance in the specialty area.

De-escalation and limit-setting in forensic mental health units.

Limit-setting and de-escalation are commonly used nursing interventions that are critical to the effective maintenance of the therapeutic milieu and the prevention and management of aggression in forensic mental health units. However, despite their purported importance, the techniques used in these interventions are rarely described. Further, these techniques are seldom based on empirical research or derived from a theory or model of aggression or interpersonal behavior. The purpose of this review is to examine the extant literature on limit-setting and de-escalation and consider how these activities could be enhanced. In concluding, this review emphasizes the potential benefits of drawing upon (1) a model of aggressive behavior and (2) a theory and literature examining interpersonal behavior, to enhance limit-setting and de-escalation skills.

Factors associated with seclusion in a statewide forensic psychiatric service in Australia over a 2-year period.

Despite seclusion being described as one of the most ethically- and legally-controversial management options available, it remains a widely-used clinical strategy for managing disruptive, aggressive, and violent behaviour. This study sought to determine how frequently seclusion was used, the common characteristics of those secluded and not secluded, and the degree to which the Level of Service Inventory - Revised: Screening Version (LSI-R: SV) could predict seclusion. The study was retrospective, covering the first 2 years of operation of a statewide forensic psychiatry hospital in Victoria, Australia. Data were collected from individual case files, electronic databases, and paper copies of records pertaining to violent incidents and episodes of seclusion. Eighty five (44%) of the 193 patients admitted during this period were secluded. Those secluded were significantly younger and had a more established psychiatric history. LSI-R: SV scores were significantly and positively associated with being secluded. A statistical model containing three LSI-R: SV items, along with age on admission and psychiatric history, achieved an area under the curve of 0.74. Seclusion is used on a regular basis in response to a range of different forms of aggressive behaviour of different severity. The LSI-R: SV demonstrated moderate-to-good accuracy in predicting seclusion and warrants further research using detailed prospective methodologies.

So what is so good about clinical experience? A mental health nursing perspective.

The available literature suggests that undergraduate nursing students generally do not have positive attitudes towards working in the mental health field but that clinical experience is the most important factor influencing the development of a more favourable outlook. Despite this there is very little attention paid to the factors that contribute to a positive clinical experience. The aim of this paper is to examine the level of, and factors contributing to, undergraduate nursing students' satisfaction with clinical experience. A survey was administered to undergraduate nursing students (n=146). The findings support the available literature in suggesting that the provision of support and the ability to become actively involved in patient care are the two most important factors affecting the perceived quality of clinical placements. However, this study contradicts the findings of earlier research in demonstrating a higher degree of satisfaction with clinical experience in inpatient settings. This reflected the view that there was less opportunity for patient care involvement within the community environment. Given the increased emphasis on community care, it is important that students are actively engaged in the care and treatment process in order that they have the opportunity to meet learning objectives in the mental health field.

Impact of theory and clinical placement on undergraduate students' mental health nursing knowledge, skills, and attitudes.

Mental health issues are common and contemporary nursing students need to be well prepared to meet the mental health care needs of Australians. This study explored the influence of the mental health component of a Bachelor of Nursing course on second-year undergraduate nursing students' self-reported knowledge, skills, and attitudes in relation to mental health nursing. The study used a quasiexperimental research design involving questionnaires and individual interviews to determine nursing students' self-reported knowledge, skills, attitudes. Questionnaires were administered prior to undertaking the mental health theory, repeated prior to undertaking a clinical placement in either a community or inpatient mental health setting, and again after the clinical placement. The findings of the study indicated that a positive clinical placement had the greatest influence on nursing students' self-reported knowledge, skills, and attitudes and interest in nursing people experiencing mental health problems; however, the quantity of theoretical education also emerged as an influencing variable.

Evaluation of a forensic psychiatric setting to provide a graduate nurse programme.

There has been growth in the number and diversity of models of Australian graduate nurse programmes in psychiatric nursing. Programmes have also been established in specialist areas, and evidence is needed regarding best models of graduate nurse programmes and the ability of specialist areas to prepare nurses for psychiatric nursing. This paper reports on a qualitative project that examined the adequacy of a forensic psychiatric hospital to provide a graduate nurse programme. Individual, semistructured interviews were undertaken with nurses participating in the programme, and nurses who had completed the programme and had remained at the hospital or were nursing in other areas. Participants identified that the environment was safe and supportive of professional practice and development, and that skilled nurses were willing to encourage and teach graduates. Processes such as orientation, preceptorship and academic study were appreciated; however, their colleagues' willingness to be available, to teach, and to support were more valued. Participants reported that they felt confident and prepared as psychiatric nurses. Although limitations of undertaking a graduate nurse programme in a forensic setting were identified, the participants from past programmes who had gone on to work in other services did not report that their nursing careers had been disadvantaged. It can be concluded that as long as the context of the programme has adequate resources to support and assist graduates to develop the skills, knowledge and attitudes of psychiatric nursing, then the specialist nature may not be a limitation.

Staff gender ratio and aggression in a forensic psychiatric hospital.

Gender balance in acute psychiatric inpatient units remains a contentious issue. In terms of maintaining staff and patient safety, 'balance' is often considered by ensuring there are 'sufficient' male nurses present on each shift. In an ongoing programme of research into aggression, the authors investigated reported incidents of patient aggression and examined the gender ratio on each shift over a 6-month period. Contrary to the popular notion that a particular gender ratio might have some relationship with the likelihood of aggressive incidents, there was no statistically significant difference in the proportion of male staff working on the shifts when there was an aggressive incident compared with the shifts when there was no aggressive incident. Further, when an incident did occur, the severity of the incident bore no relationship with the proportion of male staff working on the shift. Nor did the gender of the shift leader have an impact on the decision to seclude the patient or the likelihood of completing an incident form following an aggressive incident. Staff confidence in managing aggression may be influenced by the presence of male staff. Further, aspects of prevention and management may be influenced by staff gender. However, results suggest there is no evidence that the frequency or severity of aggression is influenced by staff gender ratio.

Changing the culture of mental health nursing: the contribution of nursing clinical development units.

The reluctance of nurses to utilise research findings in their practice has been extensively discussed in the literature. Nursing Clinical Development Units (NCDU) represent one approach to facilitating a greater interaction between research and nursing practice. This paper presents the results of an impact evaluation of an NCDU program operating in Victoria, Australia. In-depth interviews were conducted with participants in the NCDU program (n = 14). The findings suggest an increase in accessing and ultilising research by nurses since the introduction of the program, with an increased focus on evidence-based practice.

Exploring the impact of the implementation of a nursing clinical development unit program: what outcomes are evident?

Nursing Clinical Development Units have become popular as a framework for the facilitation of the professional development of nursing and to contribute to improved outcomes for consumers of health care services. An exploratory evaluation of the Nursing Clinical Development Unit program implemented by the Centre for Psychiatric Nursing Research and Practice was undertaken using a qualitative approach. This paper focuses on the findings relating to outcomes. A number of positive outcomes were identified including: changes within nursing practices; the development of more positive attitudes by nurses, a greater focus on research utilization and evidence-based practice; and an increase in professional development activities, including conference presentations. Despite these positive findings, the need for more structured evaluation and an increased emphasis on dissemination of findings was identified.

Burnout and job satisfaction: a comparative study of psychiatric nurses from forensic and a mainstream mental health service.

Within the nursing profession stress and burnout are considered to be widely present and problematic. These factors tend to impact negatively on job satisfaction and ultimately affect the retention of nurses. Psychiatric/mental health nursing as a specialty is considered to be a highly stressful environment; however, there is a paucity of research in this area. The current study adopted a survey design to compare forensic psychiatric nurses (n = 51) with psychiatric nurses from a mainstreamed mental health service (n = 78) in relation to burnout and job satisfaction. Forensic nurses displayed lower burnout and higher job satisfaction than their counterparts from the mainstreamed services. These findings are surprising in light of the image of forensic psychiatric nursing as dangerous and unpredictable.

Changing the mental health nursing culture: the nursing clinical development unit approach.

Developments in nursing as a profession have been accompanied by a perceived need to increase the relevance of research to nursing practice. The increased exposure to research in nursing curricula and the development of nursing academia has had little impact on either the conduct of clinical research or its utilization within the work place culture. Nursing Clinical Development Units (NCDU) were established with the view to overcoming some of these barriers through partnerships between academia and the clinical field. The aim of NCDU is to strive for improved patient outcomes. Education and research activities should be directed to achieve this patient-orientated outcome. The aim of this paper is to describe the NCDU program introduced by the Centre for Psychiatric Nursing Research and Practice (CPNRP) in Melbourne, Victoria. The way in which the program is designed to facilitate the relationship between CPNRP and the clinical field with the aim of contributing to improved patient outcomes will be emphasized. An evaluation of the program to date suggests that such links will be strengthened, and that this partnership will contribute to a greater involvement in clinically based research.