Nicole Ricard’s research while affiliated with Université de Montréal and other places

New professional legislation and reorganization of mental health services have had a significant influence on mental health nursing practice. Many nurses have demonstrated clinical leadership and have been able to adapt their services to the needs of the population specially in the primary health care setting. However, many believe that the role of nurses is not sufficiently known and optimally utilized in mental health services. In this article we take a critical look at the mental health nursing practice in Quebec and at the essential requirements for its development. This review aims to: 1) describe current trends in the changing roles and the modernization of mental health nursing practice in Quebec, 2) provide an overview of the development of advanced nursing practice and its impact on the quality of mental health services; 3) clarify the concept of advanced nursing practice and position its development in Quebec and 4) propose various strategies for optimizing the role of nurses and their complementarity with other professionals providing mental health services. This review presents innovative practices developed by nurses in the context of the restructuring of mental health services. For example, new nursing roles have been developed to improve the collaboration with general practitioners groups in primary care settings and facilitate the evaluation and monitoring of patient presenting medical and psychological problems. Another interesting innovation was set up by nurses in developing a new service to allow timely access to integrated care for patients with substance abuse and mental health problems. The various testimonies reported in this article illustrate the potential contribution of these nursing innovations in improving the mental health services in Quebec. Also, in few countries, the reform of mental health services has been a good time to recognize this potential. Thus, some countries have repositioned the role of mental health nurses and supported the development of new models of advanced practice in mental health. These developments have been particularly significant in the United States and Australia. In United States, during the 1990s, at least four models of advanced practice in mental health nursing have been developed leading to wide variations in the roles, education, job titles, scope of practice and legal authorizations. Consequently, a consensus model of uniform standards of practice, accreditation and education has been proposed. This LACE model (Licensure, Accreditation, Certification, Education) will be in effect in 2015. Australia has adopted a more systematic approach, unified and progressive to facilitate the development of advanced mental health nursing practice. Australia who, through their many publications, retains more attention since a clear definition of the role of the nurse practitioner in mental health and a legal framework has been adopted at the national level. The Australian experience and the finding from studies suggest that mental health nurse practitioners and nurses who are specialized in mental health have the potential to make a significant contribution to enhancing access to and quality of mental health care through flexible an innovative approaches. So there are more and more evidence and indications that Quebec should invest in enhancing the skills of mental health nurses through the development of advanced nursing practice and integration of this new model in primary care. In addition, researches, funded by the Canadian Services Research Foundation (CHSRF, 2010), shows that the contribution of advanced nursing practice has never been stronger and there is a broad consensus to its value for the Canadian health care system (Dicenso.et Lukosius-Briant, 2010). The implementation of advanced practice nursing role in mental health is part of best practices required to improve care and mental health services and should be taken into account in future Action Plan 2014-2020.

La refonte des lois professionnelles et la réorganisation des services en santé mentale ont eu une influence significative sur la pratique infirmière en santé mentale au Québec. De nombreuses infirmières ont fait preuve de leadership clinique et ont su adapter leurs services aux besoins de la population selon les nouveaux milieux de soins de proximité. Cependant, plusieurs sont d’avis que le rôle des infirmières n’est pas suffisamment connu et mis à profit pour contribuer de façon optimale à l’offre de services en santé mentale. Ainsi, cet article porte un regard critique sur la pratique infirmière en santé mentale au Québec et les conditions essentielles à son évolution. Il vise à : 1) décrire les tendances actuelles qui caractérisent l’évolution des rôles et la modernisation de la pratique infirmière en santé mentale au Québec ; 2) offrir un aperçu de l’évolution de la pratique infirmière avancée en santé mentale (PIA-SM) et de ses retombées sur la qualité des services ; 3) clarifier le concept de PIA et situer son évolution au Québec ; et 4) proposer diverses stratégies visant à optimiser le rôle des infirmières et leur complémentarité avec les autres professionnels dans l’offre de services en santé mentale. Les progrès en cours sont illustrés par des exemples de pratiques innovantes développées par des infirmières québécoises dans le contexte de la restructuration des services de santé. Les données quant à l’évolution de la PIA-SM aux États-Unis et en Australie indiquent qu’il existe encore de nombreux défis liés à l’implantation réussie de ce nouveau rôle. Toutefois, il se dégage, de la majorité des études, un consensus de plus en plus important quant à la contribution de la PIA-SM pour améliorer la qualité et l’accessibilité des soins en santé mentale. La réforme des services de santé mentale au Québec s’avère donc être un moment propice pour développer et soutenir la PIA-SM et en retirer les bénéfices attendus.

A number of frontline mental health care teams have been established in Quebec. These teams have evolved by trial and error, without the benefit of an explicit model. A case study, based on a constructivist approach, sought to assist a team in enunciating and consolidating its intervention model. Two groups, the team (n = 16) and its partners (n = 42), participated in the study. A model was articulated, but it does not appear to be very explicit. Trying to specify an innovative intervention model for the frontline mental health care team proved inextricably complex, and the best solution was to fall back on the existing general statement, which vaguely describes the interventions.

Instruments to measure the process--the daily activities of home care workers--have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries. Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for each RQC response category and rater agreement with a criterion measure (coded vignettes) were evaluated. Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories. The new RQC may support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions.

Background: In Montreal Canada, the majority of persons with serious mental illness discharged from psychiatric hospitals were placed into foster homes. Very little updated information exists on life in foster homes, and the level of autonomy allowed in this residential setting. Aims: The purpose of the study was to elicit the foster home residents' opinions about their lives in this setting and their caregiver's perception of the level of autonomy allowed. Method: Two questionnaires were administered to 102 foster home residents and their caregivers: (1) Patient Attitude Questionnaire and (2) Hospital and Hostel Practices Profile Survey. Results: Consumers are satisfied living in this type of milieu and do not desire to change their housing. The foster home provides residents with a sense of security and well being. Foster homes rank second in terms of autonomy when compared to hospitals and hostels. Only supported apartments rank higher. Conclusion: These findings shed a new light on this type of residential milieu. Over time the structure of foster homes has evolved. This study points to the need to value the opinions of consumers and not force people to move onto other types of housing.

The recovery process is characterized by the interaction of a set of individual, environmental and organizational conditions common to different people suffering with a mental health problem. The fact that most of the studies have been working with schizophrenic patients we cannot extend what has been learned about the process of recovery to other types of mental problem. In the meantime, the prevalence of anxiety, affective and borderline personality disorders continues to increase, imposing a significant socioeconomic burden on the Canadian healthcare system and on the patients, their family and significant other 1. The aim of this study is to put forward a theoretical model of the recovery process for people with mental health problem schizophrenic, affective, anxiety and borderline personality disorders, family members and a significant care provider. To operationalize the study, a qualitative, inductive design was chosen. Qualitative research open the way to learning -- the inside -- about different perspectives and issues people face in their process of recovery. The study proposal is involving a multisite study that will be conducted in three different cities of the Province of Québec in Canada: Montréal, Québec and Trois-Rivières. The plan is to select 108 participants, divided into four comparison groups representing four types of mental health problem. Each comparison group (n = 27) will be made up of 9 units. Each unit will comprise one person with a mental health problem (schizophrenia, affective anxiety, and borderline personality disorders. Data will be collected through semi-structured open-ended interview. The in-depth qualitative analysis inspired from the grounded theory approach will permit the illustration of the recovery process. The transformation of our Health Care System and the importance being put on the people well-being and autonomy development of the person who are suffering with mental problem This study protocol follows-up on earlier theory-building process that begun with the work of Noiseux 2. The contribution of the present study is to increase the comprehension of the concept of recovery and to enhance the body of knowledge in that domain. Very few studies have examined recovery and the one that did used a descriptive approach which did not take into account the perspective of the family members and the caregivers of the recovery process.

Background: Advances in knowledge in the biomedical and psychosocial sciences have expanded our understanding of schizophrenia and of how it evolves in people living with it. These individuals are no longer viewed as being 'ill' and requiring long-term hospitalisation. We have come instead to have a much more positive view of them and of the role they can play in coming to terms both with their health condition and with society. In the majority of cases, schizophrenia sufferers have the potential to recover. Aims: The purpose of this study is to propose a theoretical explanation of recovery based on the concept of human responses put forward by the American Nurses' Association. Participants: Data were collected from 41 participants (16 people living with schizophrenia, 5 family members, 20 health professionals). Selection criteria required the people living with schizophrenia to be in stable health, see themselves as being in the process of recovery, and be able to speak about it. Family members were expected to have displayed a strong bond with their relative living with schizophrenia, and the health professionals to have had at least 3 years experience dealing with schizophrenia patients. Method: The Grounded Theory approach was selected because it allows for diversified data sources to be used in the empirical study of a phenomenon. It is an appropriate approach for the conceptualization of complex phenomena and the development of middle-range theory. To ensure a variety of subjects were involved, semi-structured interviews were conducted in three different settings: a specialised psychiatric hospital, a self-help group, and a community setting. Findings: Seven categories emerged from the analysis and conceptualization: perceiving schizophrenia as a 'descent into hell'; igniting a spark of hope; developing insight; activating the instinct to fight back; discovering keys to well-being; maintaining a constant equilibrium between internal and external forces; and, finally, seeing light at the end of the tunnel. Comparison of these categories led to their being consolidated into a core category in which recovery is defined as a 'process involving intrinsic, non-linear progress that is primarily generated by the role as actor that the individual adopts to rebuild his or her sense of self and to manage the imbalance between internal and external forces with the objective of charting a path through the social world and regaining a sense of well-being on all biopsychosocial levels.' Conclusion: This study of recovery from schizophrenia is conceptualised from the nursing perspective: the concept of 'Human Responses' [American Nurses Association (ANA), 1980. Nursing: A Social Policy Statement. ANA, Kansas City, MO; American Association of Neuroscience Nurses (AANN's), 2001. AANN's Neuroscience Nursing: Human Responses to Neurologic Dysfunction, second ed. W. B. Saunders Company, Philadelphia]. It was possible to go beyond a descriptive analysis and bring out the dynamics of the process through a detailed, in-depth presentation of the recovery process. The theoretical explanation we have postulated is based on the inner resources of individuals diagnosed with schizophrenia and their potential to make a recovery.

This article reports findings on the competing needs of people living in psychiatric foster homes in Montreal, Canada. Semi-structured interviews were conducted with 33 residents. Consumers describe the tensions associated with foster home life. Two overall competing needs emerged: the need to build their lives around the foster home and the need to build life beyond the foster home. Residents describe their need for security and support versus their need for greater personal autonomy, the dilemmas associated with communal living, and their struggle to envisage a positive future. These findings have important implications for mental health professionals mandated to dismantle foster homes for more autonomous housing.

This article reports the findings of a qualitative study on the contribution of foster home caregivers for people with serious mental illness. Traditionally, social workers have played a key role in the supervision of foster homes. Little is known about how the help caregivers provide is similar to, or different from, that provided by mental health professionals. Twenty semistructured interviews were conducted with caregivers operating foster homes in Montreal, Canada. With no preset theoretical framework, data analysis was inductive and ongoing, involving the identification of categories and themes. Overall findings revealed that caregivers consider themselves the real frontline workers. They claim to be available 24 hours a day, seven days a week to combine egalitarian and affective relationships with their residents and to provide them with personalized care. Caregivers are well positioned to respond immediately to crises. Caregivers also believe that their intimate and thorough familiarity with their residents allows them to assess residents differently than could social workers. These findings have implications for mental health professionals. The combined skills and expertise of nonprofessional caregivers and social workers are essential in promoting the residents' reintegration into the community.

Canadian foster homes for adults with serious mental illness are operated by non-professional caregivers, usually women, whose mandate is to support residents and reintegrate them into the community. While mental health professionals recognize that adult foster homes are an important service for this population, there is little understanding of how caregivers impact on the lives of their residents. This article draws on the findings of a larger study which examined both caregiver and resident perspectives on the helping relationship in adult foster homes. Caregiver perspectives on the values and qualities required to help people living in foster homes are reported. With no pre-set theoretical framework, this qualitative study employed an inductive approach within a naturalistic paradigm. Semi-structured interviews were conducted with 20 caregivers. Data analysis was an ongoing, 2-year process, involving the identification of categories and themes through several distinct stages. The study included Montreal adult foster homes (n=242) for persons with serious mental illness, supervised by two university-affiliated psychiatric hospitals. Twenty caregivers, selected according to years of experience and number of residents in the home, were diverse in terms of age, cultural background, family composition, education and occupational background. Caregivers possess a clearly articulated value system, and 21 specific qualities which reflect the attributes of both professional and informal helpers. These values and qualities provide caregivers with a "professional" or "vocational" orientation. A deeply held system of values and qualities is critically important to caregiver effectiveness and job satisfaction. Findings suggest that caregivers are highly motivated, and should be recognized as full participants in the mental health system at both policy and practice levels.