Journal of Psychiatric and Mental Health Nursing

Accessible summary Borderline personality disorder (BPD) is a complex and challenging mental health condition for the person and family carers who support them. This paper reports on the results of a survey of 121 family carers of people diagnosed with BPD about their experiences of being carers, their attempts to seek help for the person diagnosed with BPD and their own carer needs. It provides the first detailed account across these domains. Family carers of people diagnosed with BPD experience significant exclusion and discrimination when attempting to interact with generalist health and mental health services. Further education for all health professionals is indicated, particularly general practitioners who likely come into contact with BPD carers. All health professionals need to improve their skills and attitudes in working with people diagnosed with BPD, and also their skills and attitudes in working with BPD carers. Carers of people diagnosed with BPD may need specialist carer support that addresses their distinct information, education and support needs. Abstract There is limited understanding of the experience of family carers of people diagnosed with borderline personality disorder ( BPD ). This study aimed to explore their experiences of being carers, their attempts to seek help for the person diagnosed with BPD and their own carer needs. An invitation to participate in an online survey was distributed to carers across multiple consumer and carer organizations and mental health services, by the P rivate M ental H ealth C onsumer C arer N etwork ( A ustralia) in 2011. Responses from 121 carers showed that they experience significant challenges and discrimination when attempting to engage with and seek support from health services. Comparison with consumers’ experiences (reported elsewhere) showed that these carers have a clear understanding of the discrimination faced by people with this diagnosis, largely because they also experience exclusion and discrimination. Community carer support services were perceived as inadequate. General practitioners were an important source of support; however, they and other service providers need more education and training to support attitudinal change to address discrimination, recognize carers’ needs and provide more effective support. This study provides the first detailed account of BPD carers’ experiences across a broad range of support needs and interactions with community support and health services.

Unlabelled: This paper shows the application of a 'case mix' system (Resources Utilization Groups T18 or RUG-T18) to a Spanish long-term inpatient psychiatric sample. Objective: To examine the capacity of RUG-T18 to predict patient resource use (spent time of care) in a long-term psychiatric sample. Subjects and research design: Data included an assessment of 163 patients' characteristics, corresponding to groups of the RUG-T18, and detailed measurement of nursing staff care over a 24-h period. Results: 'Severe behavioural problems' was the most frequent RUG-T18 category. There were significant differences in the spent time of care in the different groups and high variability in the distribution of time of care within groups and in the total sample. Conclusions: The RUG T-18 system should be improved to become a useful case mix system in long-term psychiatric inpatients. The high variance intragroups could be minimized improving the psychopathological aspects of the system.

Accessible summary At the end of the 19th century, US asylum superintendents viewed psychiatric nursing education among the most important needs at state and private hospitals. Well‐trained nurses were critical to successful implementation of moral therapy, the predominant therapeutic approach of the time. Dr Patrick Murphy, superintendent of the State Hospital at Morganton (a rural western North Carolina town), began a nurse training school in 1895. The school trained a corps of nurses who were the first in their families to enter a work in health care, nearly all of their fathers were farmers and their mothers kept house. The nurses at the State Hospital at Morganton played a key role in shaping the public image about asylum care. They not only treated patients at the hospital, but also worked as private nurses in the community and as ‘nerve’ nurses at boarding homes and resort towns nearby. These nurses demonstrated laudable achievements, and were hired by other asylum superintendents who were struggling to implement nursing reforms in their hospitals. Abstract This paper argues that at the turn of the 19th century, nurses at the State Hospital in Morganton, North Carolina (now called Broughton Hospital) played critical roles in successfully implementing the best‐known therapeutic methods of the time. They were also instrumental in developing the hospital's visibility and acceptance in rural western North Carolina. When the Hospital established its first nurse training school in 1895, this corps of first‐generation western North Carolinians practising institutional nursing was highly esteemed in their field. Their skills not only served the community outside of the Hospital's walls, but were also sought out by other private and state asylums.

The early history of mental health nurse training is one that has only been partially researched. While some writers have discussed the content and impact of training on the development of mental health nursing, little has been written on the professional and institutional factors that influenced this development. The medical profession, psychiatry, was to play an important role in the development of training and regulation of nursing staff in the large Victorian asylums and was an important influence on the knowledge base of mental health nursing. Their professional organization, the Medico-Psychological Association (the Royal Medico-Psychological Association after 1926 when they acquired a royal prefix) produced the first textbook for asylum nurses in 1885 and established a national training scheme for them 4 years later. However, in 1919 the Nurses Registration Act established the General Nursing Council for England and Wales and this body was given statutory responsibility for the training and registration of nurses, including 'mental' nurses. They were soon to be in conflict with the Medico-Psychological Association. The two organizations continued to run their own rival training schemes for mental health nurses for over 30 years, the Royal Medico-Psychological Association finally relinquishing their role in 1951. The Royal Medico-Psychological Association scheme proved far more popular than the General Nursing Councils, with significantly more nurses participating in it. This paper discusses these organizational influences on the development of 'mental nurse' training and discusses the possible impact that they have had on the knowledge base of mental health nursing.

Accessible summary In German institutions for people with mental illness, some woman lived and worked as ‘housemothers’. In the 20th century, they played a very important role. This paper is based on interviews with people who lived in these institutions and looks at their experiences of a place where carers and people with mental illness lived together. Housemothers often spent decades living and working in the institutions. There are three main phases to their development: (1) ‘Setting out as bride: borrowed power and domination’; (2) ‘Realizing one's potential as a housemother: applied power and domination’; and (3) ‘Leaving the housemother function: lost power and domination’. The findings show that the housemothers often felt that they did not get enough recognition for what they did from the deacons. Deacons in Germany are ministers in the Protestant Church who also have special training in social care. Housemothers did not just do housework; they were also caregivers who played a decisive role in resource‐oriented care. The concepts of power and domination are very important here. The historical concept of houseparents helps us understand the current discussion about new forms of residential care homes and psychiatric care. Abstract In the 20th century, houseparent families represented a significant resource in the long‐term care of people with mental illnesses and physical disabilities in diaconical care settings in Germany. In theory, such families could therefore be understood as a type of institutional family: groups which occasionally use familial patterns of reciprocity but are not themselves families. As little empirical material on life in institutional families existed, a qualitative study was undertaken to explore the experiences of contemporary witnesses, particularly those who had experienced the duties and responsibilities of housemothers in the second half of the 20th century. This paper has combined the experiences of residents ( n = 8) and biological children of houseparents ( n = 5) from a qualitative study ( n = 42). The qualitative study took a grounded theory approach, with the phenomena of power and domination forming the central category. The findings show that life in houseparent families of the time was shaped by rules which the family members had to obey. This study explores a highly controversial area which is of great relevance for current mental health nursing practice: the power relations in diaconal families. This demonstrates the importance of integrating autonomy and empowerment into everyday communal life and contributes to professional nursing practice.

From the post-War period to the 1960s, immense changes took place in the philosophy, organization and delivery of mental health care in the UK. These changes were driven by the financial burden that Bevan's National Health Service imposed on the British Government, by the dynamism and vision of psychiatrists and mental health nurses returning from the War, and by a new social and cultural consciousness, which put minority groups such as the mentally ill onto the political agenda. This paper seeks to explore some of these complex interactions and to show how the closure of mental hospitals was the inevitable outcome of movements both inside psychiatry and far beyond it. An awareness of the historical context of mental health care can assist planners and providers to avoid the many pitfalls that have been made by our predecessors.

This study compares government records of death by suicide, in Northern Ireland, during two quinquennia in the decade 1982-1991. Specifically these quinquennia are 1982-1986 and 1987-1991. During the latter quinquennium there was an increase in rate for males in most age groups, except the 45-54 and the over 65 years age groups. However, females had an increase rate in the 15-24 and 35-54 years age groups, but have a decreased rate in the other age groups. There has been a decrease in the rate of suicides by poisoning with solids and liquids for both sexes. However, male suicide rates by more violent methods have increased substantially during the latter quinquennium. Three cohorts of males, those in the 15-24, 25-34, and 55-64 age groups, have shown substantial increases during the latter quinquennium. Suggestions for psychiatric intervention strategies are made.

Research designs and variables of interest were classified in 194 mental health psychiatric articles published between 1982 and 1992. Common variables only could be identified in 100 articles and independent and dependent variables were identified in the remaining 94 articles. The majority of research designs were descriptive. The variables pertained to diverse interests from nurse and patient perspectives, specifically including patients' behavioural responses to illness, care and caregivers. These variables were then compared by the writers to the current research foci as identified in the recent literature. As listed, these are: biological psychiatry; working with the chronically and persistently mentally ill; shifting of care to the community; working with consumers; and outcome research. There is some link between research published between 1982 and 1992 and current trends in design and a few variables of interest. However, current researchers in mental health psychiatric nursing need to change foci and their relationships with other disciplines to ensure relevancy in their research programmes.

The purpose of this study was to assess the quality of quantitative psychiatric/mental health nursing research articles published in English between 1982 and 1992, worldwide. Criteria for selection of articles included nurse authorship or co-authorship, use of a quantitative design and pertinence to an aspect of the nursing process with psychiatric/mental health patients. One hundred and ninety-four articles met these criteria. The quality of each article was assessed by two nurse experts using Duffy's Research Appraisal Checklist (RAC). Forty-six point nine per cent of the articles were rated as superior, 50% as average and 3.1% as below average. Other findings identified journals that published research articles, countries in which research was completed, applicability of funding and qualifications of the authors. The major implications of this study are that nurses can be directed to superior articles; more publication of research by nurse authors is warranted, research is being completed with little financial support, highly rated research publications tend to get funding and editorial policies affect the quality of publication.

This paper examines the powers and duties that psychiatric nurses have under the Mental Health Act 1983 with respect to the care and treatment of mentally disordered people. This statute saw for the first time specific reference to the powers and duties of psychiatric nurses. These powers and duties are primarily concerned with the nurse's role in relation to consent to treatment, the administration of medication, the right to be consulted and to ensuring that detained patients are informed of their rights under the 1983 Act. The 1983 Act also provides and extends the powers of psychiatric nurses to detain certain inpatients with mental disorder against their will. In order to avoid the potential charges of 'treatment without consent' and 'unlawful detention', it is vital that psychiatric nurses, when caring for this client group, have a sound working knowledge of their powers and duties under current legislation. The legal definitions of mental disorder are explored as well as the issue of 'treatability' for mental disorder in clinical practice.

The majority of studies exploring the use of Section 5(4) (Nurses' holding power) of the Mental Health Act 1983 are now dated, report on small numbers and have been undertaken over relatively short periods of time. A retrospective study was undertaken which sought to identify the factors associated with the use of the section in one mental health trust over a 24-year period (1983-2006). Section 5(4) was applied on 803 occasions, an average of 33.4 times per annum. The majority of sections were applied to female patients (58.4%) by male nurses (54.9%) within adult acute inpatient settings (93.4%). Significant differences were noted in the use of the section over the 24-h period but not for month of the year or day of the week. A total of 349 (43.5%) sections were implemented during doctors' 'office hours' (Monday-Friday, 9:00 h to 17:00 h). The mean length of time spent on the section was 140 min; 80.6% of patients were assessed by a doctor within 4 h; and 8.3% remained on the section for 6 h or more. The holding power was converted to another section of the Act on 642 (80%) occasions. A similar, multi-sited prospective study could be undertaken to validate the findings of this study.

Since the first manifestations of HIV infection presented in the United Kingdom in the early 1980s, there has been a dramatic increase in the incidence of HIV infection and a proliferation of diseases associated with HIV infection. HIV infection is now associated with physical, psychological, mental and neurological conditions. Many of these conditions are serious and pose a major threat to physical and mental health, with rapid deterioration of health status necessitating multiple hospital admissions to acute hospitals. The majority of people hospitalized with HIV diseases are currently being cared for on general wards. While physical needs are often well met, psychological needs are to a certain extent neglected. The literature cites numerous cases of neglect, discrimination and threats to confidentiality by health professionals, including nurses. Such psychological needs, emanating out of hospitalization, compound existing psychological needs. Nichols' (1985) Adjustment Reaction Model describes a number of stages patients may go through during the course of their illness, and to some extent the patient's psychological needs can be traced throughout the trajectory of the disease. The purpose of this paper is to review the literature and present a theoretical argument, using Nichols' model as a framework, on psychological needs of patients with HIV diseases, and attempt to outline to what extent psychological needs of patients with HIV are met in institutional care. The authors recommend further research to determine nurses' perception of the importance of meeting psychological needs of patients with HIV disease.

After a decade of community mental health care, the time is ripe for critical evaluation not only of the policy itself, but also of appropriate nurse education. This paper fills some gaps in the historical record of the early years of community care by describing some educational innovations within one of the earliest services to abandon mental hospitals. Whilst it is accepted that the libertarian, experimental nature of the courses described may be accused of contributing to the alleged early failings of community care, it is also suggested that such educational experiences may assist the establishment of positively therapeutic nursing relationships. Current modular courses are generally more tightly structured, highly assessed, research-based and technical. Recent claims suggest that whilst nurses are more highly educated, there may be a reduction in the quality of the caring relationships they establish. This account of largely unreported, process-based courses implicitly suggests that mental health nurse education might be better as a creative synthesis of such theoretical principles with today's more science-based, content-driven courses.

Violence perpetrated by people experiencing mental illness poses a continuing challenge to practitioners and policy makers in the mental health field. It has been suggested, however, that policy developments in England during the period 1990--2000 became unduly dominated by the perceived need to prevent such violence and in particular that a 'moral panic' occurred following a series of high profile homicides perpetrated by people experiencing mental illness. This paper critically examines the ability of the moral panic theory to offer a cogent explanation of the relationship between media representations, public perceptions and developments in both social policy and legislation during the last decade. Its conclusions, however, suggest that the evidence does not support assertions of a moral panic and that of moral panic theory itself has serious flaws. Ultimately the paper suggests that we must look elsewhere, particularly to Foucault's conceptualization of discourse and to the work of Birkland, an American political theorist, in our search for an understanding of the relationship between events, ideas and social policy.

The first major review of psychiatric mental health nursing in England since 1968 is now complete. The review was announced in 1992 by the Department of Health, at the Royal College of Nursing Annual Congress. A steering group was convened to conduct a review and its report was published in 1994. At the outset, the multidisciplinary group aimed to identify requirements for skilled nursing responsive to patient need, into the next century. The chairman of the review summarizes in this paper the main issues that characterize its findings. The 42 recommendations are abstracted at the end of this paper, by subject headings from the published report.

Accessible summary With the increase in numbers of people suffering from dementia there is a need for staff at all levels of nursing to be trained in, and to be knowledgeable of, the basics of the MHA 2007, MCA 2005 and DoLS. Decision‐making processes concerning observation levels on inpatient wards must be a team‐based. All individuals must be assumed to have mental capacity unless it has been proved otherwise. There is a need to develop clear and unambiguous observation policies for use on inpatient units. Abstract In England and Wales the interface between the Mental Capacity Act 2005 (MCA) and Mental Health Act 2007 (MHA ) is frequently encountered in mental health practice. In services involving older adults many service users will have cognitive impairment and dementias in some instances with behavioural and psychological symptoms of dementia and assessments regarding their mental capacity to make decisions are frequently required. Service users with these illnesses are admitted to psychiatric wards and occasionally nursed under ‘close observations’ in order to maintain their safety and that of others. The concepts of ‘complete and effective control’ which may be exercised by ward staff in these circumstances, and the resulting ‘loss of autonomy under supervision and control’ must be understood in consideration of whether a ‘deprivation of liberty’ should ensue, particularly when they do not have mental capacity to make decisions about the observations. The observation policy must clearly delineate the different forms of nursing observations possible e.g. close, constant, intermediate, general etc. to avoid confusion among staff members implementing the observation plan. Various dilemmas and management of such dilemmas concerning the use of MCA 2005, MHA 2007 and observation policies has been discussed in this paper. Nursing staff working in both psychiatric and acute hospitals need training in concepts of MCA 2005, MHA 2007 and Deprivation of Liberty Safeguards.

Accessible summary The majority of articles that have been published about recovery and mental health have been published within the 4 years preceding this literature review. However, there are very few articles that review the recovery literature; furthermore, articles that report research directly related to the recovery concept are scarce. Originally, the focus of the recovery movement was upon the role of the individual in their own recovery journey; there has been a shift towards the responsibility of service providers to ensure a recovery focused service. Tensions have emerged in the literature between the humanistic philosophy of recovery and the biomedical model that has historically informed psychiatry. Similarly, the notion of recovery may overemphasize the significance of personal agency against the responsibility of services to fulfil a duty of care. Recovery has become strongly associated with social roles and meaningful activities including education, work and engagement with sport and arts activities. Abstract This paper is the first in a series of two which reviews the contemporary British evidence‐base relating to recovery in mental health over a 4‐year period. This review uses a systematic approach analysing the British peer‐reviewed literature relating to recovery and mental health. The second paper in the series reviews the non‐peer‐reviewed literature. Recovery is not a new concept; however, it has recently become increasingly prevalent in practitioner, policy and research discourses. In total 12 papers met the inclusion criteria. Five main themes emerged from the analysis: hope and optimism, meaning to life, activities promoting recovery, definitions and discourses and implications for mental health practice. By including only peer‐reviewed literature this paper is in a strong position to analyse the theoretical development of the recovery concept and highlight future directions for recovery in mental health services.

This paper is the second in a series of two which reviews the current UK evidence base for recovery in mental health. As outlined in the previous paper, over the last 4 years a vast amount has written about recovery in mental health (approximately 60% of all articles). Whereas the first review focused on the peer-reviewed evidence; this paper specifically focuses on the grey/non-peer-reviewed literature. In total, our search strategy yielded the following: 3 books, a further 11 book chapters, 12 papers, 6 policy documents and 3 publications from voluntary sector organizations. Each group of publications was analysed for content, and they are discursively presented by publication group. The findings are then presented as themes in the discussion section. The themes are: social, historical and political critique; philosophy of hope for the individual; individual identity and narrative; models and guidance for mental health practice. We conclude that there is a need for both empirical research into recovery and a clearer theoretical exposition of the concept.