Considering the Contemporary Issues and Unresolved Challenges Facing Therapeutic Communities for Clients with Alcohol and Substance Abuse.

Alcohol and substance abuse remain significant public health problems in many parts of the occidental world. Some facilities that provide treatment for such abuse often refer to themselves as "Therapeutic Communities" (TCs). However, fundamental compositional differences in TCs present unresolved issues and as such, create significant implications for research, practice, education, and substance/alcohol care policy. Accordingly, this paper examines the heterogeneity and efficacy of TCs; the treatment approaches of harm reduction and abstinence; the training of TC staff and workers; and the recommended length of stay for individuals seeking recovery.

Hope and interpersonal psychiatric/mental health nursing: a systematic review of the literature--part one.

Psychiatric/mental health (P/MH) nursing is inherently an interpersonal endeavour; one that includes a broad range of 'helping activities'. The interpersonal activities and skills are enshrined in our underpinning philosophy, explored and learned in our curricula (all around the world) and enacted in our everyday clinical practice. Within this interpersonal context and framework, it is heartening to see that understated, abstract and yet-lasting concepts such as hope are gaining more acknowledgement, recognition and subsequently attention. While it is recognized that hope in mental health care is increasingly becoming the focal point of disciplined inquiry, the authors believe it is perhaps necessary and timely to re-examine these two concepts, namely: interpersonal P/MH nursing and hope/inspiring hope in people with mental health problems. Accordingly, this two-part article reports on a systematic review of the literature that focuses on hope (inspiring hope) within interpersonal (counselling) focused P/MH nursing. Part one focuses on the method used and the results, indicating that a total of 57 articles were included in the review: 39 were categorized as empirical studies involving either a quantitative or qualitative methodological design, and 18 were considered theoretical/clinical/review articles. Though not a product of an empirical investigation per se, it was clear that many of the articles shared and covered common ground. Thus, these were arranged into six 'loose' thematic groupings. The first three of these areas, schizophrenia, suicidality and depression form the remainder of part one of this article, and the remaining areas are included in part two.

Hope and interpersonal psychiatric/mental health nursing: a systematic review of the literature--part two.

This is the second of a two-part article which reports on a systematic review of the literature that focuses on hope (inspiring hope) within interpersonal (counselling) focused psychiatric/mental health (P/MH) nursing. Part one focused on the first three substantive areas, whereas this article focuses on the remaining areas and the discussion points arising out of the review. The discussion points arising are: (1) despite the increasing attention to hope over the last three decades, there remains a distinct paucity of research pertaining to P/MH nurses and hope, hoping and hopelessness; (2) the research that has been undertaken thus far lacks a cumulative, sequential progressive focus and has more of a sporadic, disparate look to it; (3) there is a dearth of empirical work to underpin specific interventions; (4) this relative absence of empirical work means that P/MH nurses often have to look to allied and/or related disciplines for their hope-related research; (5) there appears to be a disparity between the alleged importance of hope and the subsequent research activity; and (6) the research that does exist across different substantive areas appears to indicate that there might be common or shared basic psychosocial processes of hope inspiration, and thus the probability of a formal grounded theory; and this allows for idiosyncratic psychosocial processes for each substantive area. As a result of this review, the authors tentatively suggest that the inspiration of hope in P/MH nursing is grounded in the relationship established between nurse and person in need of hope, an emerging empirical finding that has obvious congruence and synchronicity with the philosophy and theory of a Peplauvian-based approach to P/MH nursing.

The principles and processes of inspiring hope in bereavement counselling: a modified grounded theory study--part one.

The concept of hope has received attention within nursing and healthcare literature of late yet it is fair to say that despite this increased interest, considerable gaps remain in our substantive knowledge base. Particularly noticeable is the paucity of empirically derived theory regarding the principles of inspiring and instilling hope in certain client groups and with persons enduring certain experiences. Accordingly, this two-part paper attempts to bridge one of these gaps by answering the question: do bereavement counsellors inspire hope in their clients and if so, how? Using a modified grounded theory method data were collected by means of semi-structured interviews; undertaken with a theoretical sample of bereavement counsellors and ex-clients who had received bereavement counselling. In keeping with the tenets of grounded theory, the data were coded and analysed using the constant comparison method, and this produced an emerging, substantive theory of the principles and processes of hope inspiration for this client group. This theory is comprised of a core variable: the implicit projection of hope and hopefulness, and three sub-core variables: forging the connection and the relationship; facilitating a cathartic release; and experiencing a healthy (good) ending. Given that the details of the core variable have been published previously, part one of this paper deals with a review of the literature and focuses on stage one; highlighting each of the individual categories. Where as part two focuses on stages two and three, again highlights the categories therein and offers a discussion and conclusion.

The principles and processes of inspiring hope in bereavement counselling: a modified grounded theory study--part two.

This second part of a two-part paper attempts to answer the question: do bereavement counsellors inspire hope in their clients and if so, how? Using a modified grounded theory method data were collected by means of semi-structured interviews; undertaken with a theoretical sample of bereavement counsellors and ex-clients who had received bereavement counselling. In keeping with the tenets of grounded theory, the data were coded and analysed using the constant comparison method, and this produced an emerging, substantive theory of the principles and processes of hope inspiration for this client group. This theory is comprised of a core variable: the implicit projection of hope and hopefulness, and three sub-core variables: forging the connection and the relationship; facilitating a cathartic release; and experiencing a healthy (good) ending. Part one of this paper included a review of the literature and focused on stage one. Part two on the other hand, focuses on stages two and three, and highlights the categories therein. The paper concludes by highlighting implications arising from the findings (other discussion points have been published elsewhere).

The Nurses' Global Assessment of Suicide Risk (NGASR): developing a tool for clinical practice.

Contemporary and established literature indicates that people with mental health problems are at a higher risk of suicide than the general population. Because suicide is a multifaceted, complex phenomenon, risk assessment within the mental health care system requires a pluralistic, multidimensional and multiprofessional response. While assessment tools may provide useful guidance, especially guarding against complacency and over confidence, the fundamental basis of risk assessment must involve a thorough examination of the personal, interpersonal and social circumstances of each individual. Such thorough and rigorous assessments, the authors of this paper would add, require a degree of 'clinical judgement'. As a rule, inexperienced members of mental health care staff should not be charged with the responsibility of conducting suicide risk assessments without sound mentorship. However, with the right support and assessment tool, the novice practitioner might develop the kind of clinical judgement necessary for this critical task. Accordingly, this paper traces the development of the Nurses' Global Assessment of Suicide Risk (NGASR). It illustrates the practice development context out of which the need for the tool arose; it outlines the key evidence that underpins the construction of the tool and it is described. It is important to point out that as yet, no wide scale, quantitative validation of the tool has been conducted. Therefore, at this point, the tool should be treated with a degree of appropriate caution. Nevertheless, the preliminary attempts that have been made to 'validate' or 'rate' the tool in practice are included. While acknowledging that any risk assessment tool represents only one aspect of the necessarily broader assessment of risk, the NGASR appears to provide a useful template for the nursing assessment of suicide risk, especially for the novice.

Building a case for understanding the lived experiences of males who attempt suicide in Alberta, Canada.

Suicide is a serious public health concern in Alberta, with, on average, over 400 Albertans taking their own lives annually. The case for concern is even more pronounced when one considers that for younger Albertans (those aged less than 45 years), suicide is the second leading cause of death. While trends in rates of suicide fluctuate over time, it is important to note that suicide rates for males have been at least three times higher than the corresponding rates for females since the 1950s. Furthermore, these differences have increased so that, by the 1990s the rate for male suicide was four times higher than that of females. In addition, rates are increasing at a faster pace in younger cohorts. Despite the existence of numerous positivistically orientated studies, and the introduction of a range of strategies to help prevent suicide, significant reductions in suicide rates have not been achieved. Similarly, while there is a substantial literature on the issue of suicide in Canada, there remain many gaps in our knowledge. Our understanding of the experiences and the meanings attributed to these experiences that motivate contemporary Albertan males to attempt suicide is far from complete. In order to design interventions to help reduce the suicide rate, whether these are interventions at the preprimary, primary or secondary level of care, it is necessary to gain a more detailed and comprehensive understanding of this highly complex behaviour. Consequently, there is an urgent need to better understand the particular life experiences and the meanings that individuals attach to these experiences. Accordingly, this paper makes the case for the use of hermeneutic, phenomenological investigations, as a means to further elucidate the lived experiences of suicidal Alberta males.

Addressing hopelessness in people with suicidal ideation: building upon the therapeutic relationship utilizing a cognitive behavioural approach.

This article reports on how the therapeutic relationship can be enhanced by utilizing a cognitive behavioural approach when dealing with hopelessness in suicidal people. A rationale is presented regarding why this topic is deemed important. Following a brief overview of the concept of hope, the theoretical and empirical literature relating to hopelessness are examined. This literature indicates that, given the inextricable link between suicide and a sense of pervasive hopelessness, it is necessary for the practitioner to understand the methods and theoretical underpinnings of hope inspiration. Two case studies, drawn from clinical practice, are described in order to elucidate the key elements/interventions (which include the therapeutic relationship and specific cognitive behavioural techniques that the nurse therapist may utilize when attempting to ameliorate the client's sense of hopelessness). These key elements/interventions are further elaborated upon. Whilst cognitive behavioural techniques are shown to be beneficial when dealing with hopelessness, it is advocated that the therapeutic relationship is a prerequisite for successful therapy.

Considering the care of the suicidal client and the case for 'engagement and inspiring hope' or 'observations'.

Psychiatric/mental health (P/MH) nursing has rightly been described as a 'broad church', and one that contains many contested matters and areas of differing opinion. One such contested matter is that of the appropriate care for the person who is at risk of suicide. Recent, albeit limited, debate of this issue has taken place, and the literature, such as it is, indicates two principal (though linked) positions. These can be summarized as the 'engagement and hope inspiration' position and the 'observations' position. Given the P/MH nurse's unique position in providing 24-hour, day-to-day care to suicidal clients and the growing problem of suicide within people who suffer from mental health problems, it is both necessary and perhaps timely to consider this debate in more detail. Accordingly, this paper considers the debate regarding care for suicidal mental health care clients. First, the paper briefly describes the historical policy context of care for the suicidal client. Next, it focuses on 'observations' and concludes that there is a range of well-established, empirically based problems or drawbacks to this approach. Following this, it focuses on 'engagement, inspiring hope' and points out the key processes of engagement: forming a relationship, a human-human connection, conveying acceptance and tolerance, and hearing and understanding. The value and importance of these most fundamental of interpersonal processes is described and alluded to throughout the limited research into care of the suicidal client. The paper then describes the range of criticisms that have been levelled at the engagement-inspiring hope approach and considers these criticisms in more detail. As a result of this detailed examination, the paper then reiterates the need to replace 'observations' with 'engagement-hope inspiration' as the principal approach to caring for suicidal mental health clients.

Mass media, 'monsters' and mental health clients: the need for increased lobbying.

A review of the limited empirical and theoretical literature indicates that current mass media representations of mental health service users appear to emphasize violence, dangerousness and criminality. This is despite the empirical evidence that indicates a decline over the last 40 years in the number of homicides carried out by people identified as suffering from mental health problems. Such inappropriate representations do much to increase stigma, ostracism, harassment and victimization of these individuals by the public. Furthermore, it can be argued that there is another repercussion of these representations and that is the subsequent government position/policy and the resulting legislation concerning care of people with mental health problems. Consequently, this paper argues that there is a clear need for psychiatric/mental health (P/MH) nurses to become more mindful of the wider, socio-political environment in which their practice occurs, particularly if psycho-social approaches to practice are adopted in their fullest sense, and as a result increase their political lobby. Such increased lobbying should occur on behalf of, and in collaboration with, service users, and accordingly the authors describe a range of activities under the broad headings of pro-active and reactive lobbying. Furthermore, it is incumbent upon P/MH nurse educationalists to prepare aspirant P/MH nurses for this lobbying role and equip them with the skills necessary to do so.

What are the principles and processes of inspiring hope in cognitively impaired older adults within a continuing care environment?

This study focuses on the principles and processes that psychiatric/mental health (P/MH) nurses use to inspire hope in cognitively impaired older adults within a National Health Service (NHS) continuing care environment. Using a grounded theory method, the data were coded and analysed, in an attempt to produce an integrated conceptual framework of hope inspiration. This comprised four core variables: applied humanistic code, pragmatic knowledge, interpersonal relations and nurse as utilizer. The authors postulate a relationship between the function of caring, the activity of helping and the practice of instilling hope, as a basis for suggesting that inspiring hope to clients is one of the primary acts of P/MH nursing. The authors conclude that the four core variables are intertwined and inseparable from one another, and bound up with P/MH nursing practice. From this position, it is suggested that the processes of inspiring and instilling hope cannot be separated from the qualities of being a P/MH nurse. However, a more detailed and complete understanding of the concept of hope can increase the nurse's effectiveness as a carer.

Judging the ethics of qualitative research: considering the "ethics as process" model.

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.

The commonality and synchronicity of mental health nurses and palliative care nurses: closer than you think? Part one.

The role of the palliative care nurse emphasizes the need for holistic care, and as this role has developed it has become evident that palliative care nurses require skills which, arguably, not all registered general nurses possess; particularly, skills pertaining to the psychological, social and spiritual domains of the person. In order to identify the skills that such nurses may require, there may be merit in considering other specialities of nursing which pay particular attention to the psychological, social and spiritual domains of the person. Consequently, this two-part paper explores the areas of commonality and synchronicity between palliative care nurses and mental health nurses. The authors argue that this commonality is best articulated under the headings: defining the needs of the client group, the role of the nurse in non-physical care, the nurse--client relationship, and the locus of control. They also argue that the differences between these groups of nurses are best articulated under the headings: facilitation/confrontation, and the focus on physical care. Part one of this paper therefore focuses on the first three areas of alleged commonality, with part two focusing on the fourth commonality, the key differences and the implications of such similarity. Given these areas of similarity the authors argue there is a case for reconsidering if the RGN qualification is an essential requirement for working within palliative care or if those with other skills -- skills based on 'being with' rather than 'doing for' -- such as RMNs, should be thought of for such roles.

The commonality and synchronicity of mental health nurses and palliative care nurses: closer than you think? Part two.

This is the second of a two-part paper which explores the areas of commonality and synchronicity between palliative care (PC) nurses and mental health nurses. The authors argue that this commonality is best articulated under the headings: defining the needs of the client group, the role of the nurse in non-physical care, the nurse--client relationship, and the locus of control. They also argue that the differences between these groups of nurses are best articulated under the headings: facilitation/confrontation and the focus on physical care. Part one focused on the first three areas of commonality, whereas this paper focuses on the fourth commonality, the locus of control. It also focuses on key differences and the implications of such similarity. The paper highlights the practice, education and research implications of this alleged commonality. It suggests, given the evidence that clients perceive the therapeutic relationship as the vital and unique aspect of PC nursing, that those working within palliative care need to question whether or not RGN registration is an essential requirement, or whether those with other skills, such as psychiatric/mental health (P/MH) nurses, should be considered for such roles. It highlights the need for the provision of post-basic counselling courses and the potential value for PC nurses of receiving clinical supervision from P/MH nurses or mental health liaison nurses. Lastly, it posits that the research issues arising out of this alleged commonality centre on the potential impact such transitions in care delivery may have on the care delivered, on the nurses themselves and on the clients.