The impact of suicidal deaths of children and adolescents among parents and mental health professionals: A systematic review and meta-synthesis.

The Impact of Patient Suicide on the Professional Reactions and Practices of Mental Health Caregivers and Social Workers

In the last decade, advances have been made in identifying young people who may be at relatively high risk (HR) of developing psychosis. Given the controversial and experimental nature of the HR concept, the attitudes and experiences of mental health professionals and patients are likely to influence practice in this area. Previous work has been published that has speculated on the potential risks and advantages of identifying and intervening within the HR state. However, few have attempted to capture the attitudes and experiences of patients and professionals towards this concept. This article provides, via the collation of existing research reports, a reflection on the views, attitudes and experiences of these key stakeholders. A narrative review of the literature was undertaken focussing upon the following key areas: mental health professionals' attitudes towards the HR concept, patients' attitudes towards the HR concept, attitudes of patients towards potential treatments and attitudes of professionals towards HR treatments. Relatively few published studies focusing on the attitudes and experiences of patients and mental health professionals exist. However, there is some evidence that both professionals and affected individuals view the HR concept as worthy of diagnosis and intervention. Expressed treatment preferences appear to vary, dependent on the group of individuals surveyed. Further systematic studies of patient and professional preferences, in relation to identification and intervention, are desirable in order to explore the way that the HR denotation is personally interpreted and the extent to which it affects patient and practitioner behaviour.

The experiences of mental health professionals' and patients' use of pro re nata (PRN) medication in acute adult mental health care settings: a systematic review protocol of qualitative evidence

Review question/objective The objective of this review is to synthesize the best available qualitative evidence on the experiences of mental health professionals and patients with the use of pro re nata (PRN) medication in acute mental health care settings. More specifically, the review question is: what do mental health professionals experience when they administer or prescribe PRN medications and what do patients who receive these PRN medications experience? Background Pro re nata medication means "when necessary" from the Latin phrase pro re nata which means for an occasion that has arisen, as circumstances require, as needed.1 The most common types of PRN medications administered by mental health professionals in acute mental health care settings are psychotropic medications. The word "psychotropic" comes from the Greek word psycho which has a combined meaning of psyche, which indicates the mind, soul or spirit, as opposed to the body,1 and tropo or tropos, the Greek word which means turning, hence, "what turns the mind".2 Psychotropic medications affect chemical levels in the brain which can affect mood, perception and behavior.2 When a medical officer writes an order for PRN medication they will write an order for one or more medications to be given to the patient at the mental health professional's discretion. This is providing that the documented specifications for administration are met.3 The documented specifications on the medication chart are specifically about the dose of medication and the circumstances under which the medication should be given. The reasoning behind this is that by having these medications available to use at times when a patient is acutely unwell, agitation or violence in the acute mental health setting may be prevented or contained without having to call a medical officer to prescribe medication.3 There has been a considerable number of studies conducted on the use of PRN medication in acute mental health care settings. The authors of a quantitative Cochrane systematic review compared "as required" medication regimens with regular medication regimens for severely mentally ill people in hospital.4 Twenty-two papers were included in the review. Some of the papers included reported that PRN medication was used comprehensively in psychiatric facilities to manage patients who were suffering agitation or who were disturbed or distressed.5 Twenty-three percent of inpatients in mental health facilities were found to have had at least one PRN dose of medication during their hospital stay.6 A total of 50% of patients in secure mental health care received PRN medication while admitted.7 Once PRN medication is prescribed, it is administered regularly, sometimes up to 10 times per patient and most of these in the four days within admission.8 The authors of the Cochrane systematic review found that although the practice of using PRN medication is standard practice, there was no evidence found from the review that PRN use was the best way of dealing with agitation among those mental health patients when compared to regular doses of medication.4 While the Cochrane systematic review examined the effectiveness of PRN medication for seriously mentally ill people, Baker et al.9 conducted a best evidence synthesis on drug use/administration of PRN medication in mental health wards. Best evidence synthesis involves the analysis of quantitative papers, supplemented by a review of the broader literature that may result in a qualitative analysis.9 Baker's synthesis found that psychotropic PRN administration was wide-ranging and that there were many factors involved in determining administration.9 Baker highlighted the need to understand the clinical decision making around this practice. He found that practice varied widely.9 Baker's research highlighted some of the areas around administration of PRN medication, including the frequency of when it was given, how often it was given in a 24 hour period, what was administered by what route, and what the effects and side-effects of the medications were.9 Some additional research conducted on the use of PRN medication includes retrospective studies in which case notes were audited, and administration practices were examined.10,11 Other studies have looked at antecedents to PRN administration, activities to reduce PRN medication administration and literature reviews.12–14 Much of the research conducted on the administration of PRN medication within mental health care settings has focused on quantitative research and from only the perspective of the nurse. The patient's experience of PRN medication use in adult acute mental health care settings is an area that is lacking in understanding, as few studies have explored the administration of PRN medication from a patient's perspective. Research by Baker et al. into service users' experiences of "as needed" medication concluded that service users or patients found that PRN medications were useful but they appeared to have only a limited understanding of the use of PRN medication and possible alternatives to its use.15 Baker et al. also reported that the process around the use of PRN medication could be stigmatizing and confusing, and that nurses should provide the patients with information about PRN medication as well as any other treatment choices.15 Further research by Cleary et al. into patients' views and experiences of PRN medication found that the majority of patients were able to talk about at least one use of PRN medication that provided relief for them. Cleary et al. found that from the patients' perspective, interactions with patients around the immediate administration of PRN medication were inadequate.16 Gaining an understanding of mental health professionals' and patients' use of PRN medications is important as the literature shows that there are many variables in the administration of PRN medication in acute adult mental health care settings. Understanding how a patient feels about this practice and understanding how mental health professionals make decisions around this practice are also important. The aim of this systematic review is to provide a deeper understanding of the circumstances and factors that influence a mental health professional and their use of PRN medication. This systematic review will endeavor to locate evidence of the use of PRN medications by mental health professionals including the clinical decision-making process when administering and prescribing PRN medication. This review will also endeavor to find evidence of patients' understanding and viewpoints on the use of PRN medication. A search of the Joanna Briggs Institute Database of Systematic Reviews and Implementations Reports, CINAHL and PubMed databases did not find any current or planned reviews on this topic. Inclusion criteria Types of participants This review will consider studies that include mental health professionals working in an acute adult mental health care setting who prescribe and administer PRN medications as well as adults admitted to an acute adult mental health care setting. Phenomena of interest This review will consider studies that investigate mental health professionals' and patients' experiences in the use of PRN medication. Context The context for the review is acute adult inpatient mental health care settings. These settings are usually within public health systems or private mental health settings. Types of studies This review will consider English language studies only that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English language will be considered for inclusion in this review. Studies published prior to the commencement of this protocol, prior to April 2014, will be considered for inclusion in this review. The databases to be searched include: CINAHL PubMed Embase Scopus PsycINFO The search for unpublished studies will include: ProQuest Dissertations and Theses Mednar Google Scholar Initial keywords to be used will be: Nursing OR nursing staff OR nurses OR nurse OR clinician OR mental health nurses AND Pro Re Nata, OR clinical decision-making OR PRN medication OR medication administration AND Mental health AND Qualitative OR qualitative and experience OR lived experience OR perception OR perceived OR understanding OR ethnography OR phenomenology OR feminist and research OR critical and research OR action and research OR systematic review Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data extraction Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. For any missing information the primary author of papers will be contacted. Data synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. Conflicts of interest The authors declare that there are no conflicts of interest. Acknowledgements As this systematic review forms partial submission for the degree award of Masters of Clinical Science, a secondary reviewer will assist in critical appraisal and the author would like to acknowledge the input of the secondary reviewer.

BackgroundThe World Health Organization report that an estimated 793,000 people died by suicide in 2016 globally. The use of digital technology has been found to be beneficial in the delivery of Web-based suicide prevention interventions. Research on the integration of digital technology within mental health services has indicated that despite the proliferation of technology, engagement by patients and professionals in adopting such technology can be poor.ObjectivesThe current study aims to explore the experiences of 15 mental health professionals involved in integrating mobile health technology into their practice. A secondary aim was to identify the drivers and barriers to the adoption of such technology by mental health professionals, and to consider what theoretical models could best account for the data.MethodsSemi-structured interviews, conducted from July to October 2019, were used to explore the experiences of mental health professionals engaged in the adoption of mobile health technology within mental health services. Mental Health professionals and clinician managers working in HSE Child and Adolescent Mental Health, Adult Mental Health, and Primary Care Psychology services were recruited for the study. Qualitative interview data was transcribed and analysed using NVivo. Thematic Analysis was used to identify themes.ResultsFour major themes were identified: Accessibility, ‘Transitional Object’, Integration, and Trust. Within these 4 major themes, a total of 9 subthemes were identified: Service Accessibility, Immediate Access, Client Engagement, Adjunct-to-therapy, Therapeutic Relationship, Infrastructural Support, Enhancing Treatment, Trust in the Technology, Trust in the Organisation.ConclusionsOverall, Diffusion of Innovation Theory provides a useful theoretical framework which is consistent with and can adequately account for many of the Major and Subthemes identified in the data. In addition, ‘Transitional Objects’, a key concept within Object Relations Theory, could offer a means of better understanding how patients and professionals engage with digital technology within mental health services particularly.

Many forced migrants experience trauma in pre-migration, journeying, and post-migration phases of flight. Therefore appropriate mental health provision is required. Whilst previous reviews have explored the experiences of health-care staff in supporting forced migrants, no review was found that focused solely on the experiences of mental health professionals. This qualitative thematic synthesis integrates the findings from ten qualitative studies and identifies analytical constructs that encompass the challenges and facilitators for mental health professionals. Findings will inform how services can be developed to best support staff and enable the provision of high-quality mental health care for this potentially vulnerable population.

Whilst formal coercion in psychiatry is regulated by legislation, other interventions that are often referred to as informal coercion are less regulated. It remains unclear to what extent these interventions are, and how they are used, in mental healthcare. This paper aims to identify the attitudes and experiences of mental health professionals towards the use of informal coercion across countries with differing sociocultural contexts. Focus groups with mental health professionals were conducted in ten countries with different sociocultural contexts (Canada, Chile, Croatia, Germany, Italy, Mexico, Norway, Spain, Sweden, United Kingdom). Five common themes were identified: (a) a belief that informal coercion is effective; (b) an often uncomfortable feeling using it; (c) an explicit as well as (d) implicit dissonance between attitudes and practice-with wider use of informal coercion than is thought right in theory; (e) a link to principles of paternalism and responsibility versus respect for the patient's autonomy. A disapproval of informal coercion in theory is often overridden in practice. This dissonance occurs across different sociocultural contexts, tends to make professionals feel uneasy, and requires more debate and guidance.

<h3></h3> The purpose of this modified critical review of literature is to draw upon the contemporary evidence base to explore the lived experiences of healthcare professionals delivering end-of-life care to patients cared for in mental healthcare settings. People of severe and persistent mental illness are a very vulnerable cohort of patients. They often live with higher-than-average co-morbidities, low than average life expectancy and high mortality rates. Little is known about the experience of mental health professionals delivering end-of-life care to those patients whose care needs can only be met in an in-patient facility. This review aims to provide a window into this experience and draw out the barriers and enablers to good care. For this review, 64 unique titles and abstracts were identified through the search of six databases. The appraisal of these papers resulted in six meeting the inclusion and quality criteria and subsequent syntheses of the findings were presented into three themes: 1) There was a recurrent lack of preparedness of both services and staff to assess and meet the needs of patients at the end-of-life in mental healthcare settings. 2) There was a clear need for collaborative work between mental and physical healthcare professionals; however, this was often difficult to achieve. 3) Patients at the end-of-life with Severe Mental Illness poses specifically challenges which professional caring for them need to be aware of. The findings of the review were in keeping with other work in the area and provides four main recommendations for practice: 1) Services must have a clearly defined collaborative approach to working relationships between palliative care and mental healthcare professionals. 2) Specific training and education for mental healthcare professionals in end-of-life care and visa verse for physical healthcare professionals when caring for a patient with a comorbid serious mental illness. 3) Thought should be put into the environment of an in-patient mental healthcare ward. While it is recognised the need to maintain safety of patients in these environments, considerations such as the availability to the correct equipment, décor and access to meaningful activity is invaluable for both care giver and patient. 4) Services should consider that their policies and procedures reflect that end-of-life care could be a need of any patient in a services care. The ability to refer to policy and procedure was found to be a comfort and a supportive measure for staff caring for patients at the end-of-life.

Persons with communication disorders are susceptible to mental health difficulties and often require the help of mental healthcare professionals. Mental healthcare interventions require a significant amount of communication between the mental healthcare professional and the person with communication disorders, yet not much is known about how mental healthcare professionals provide mental healthcare services to persons with communication disorders. The study, therefore, aims to explore the experiences of mental healthcare professionals in providing mental healthcare services to persons with communication disorders. A qualitative phenomenological research approach was employed, where 11 semi-structured interviews were conducted with mental healthcare professionals practising in the Gauteng Province of South Africa (n = 7 social workers; n = 3 psychologists; n = 1 counsellor). Participants were purposively selected for the study. Data were analysed using inductive reflexive thematic analysis. The following four themes emerged from the data that were analysed: (i) lack of preparedness to provide care to persons with communication disorders, (ii) communication barriers, (iii) emotional effects and (iv) accommodations. Findings suggest that communication barriers are a source of frustration, and they hinder persons with communication disorders from accessing quality mental healthcare services. There is therefore a need to include in the curriculum of mental healthcare professionals, training on communication disorders and on strategies to foster communication with this population during intervention. Conversational partner training and collaborations between mental healthcare professionals and speech language therapists could potentially be used to address the communication barriers in mental healthcare provision for persons with communication disorders. What is already known on this subject Persons with communication disorders are susceptible to mental health difficulties because the communication impairment reduces their societal and economic inclusivity, thus placing them at a higher risk of developing mental health challenges. Unfortunately access to quality mental healthcare services is a challenge for this population for many reasons, with the most pronounced one being the fact that they do not depend on verbal language to communicate their needs (are voiceless) and require reasonable accommodation to facilitate communication, yet the techniques and methods used in mental healthcare intervention whether formal or informal are predominantly based on verbal communication. What this paper adds to existing knowledge The study advocates for the implementation of educational opportunities for mental healthcare providers through communication/conversational partner training programmes. These programmes can potentially improve their knowledge and skills on how to effectively support communication with persons with communication disorders, to mitigate communication challenges. Research has demonstrated positive effects of communication partner training. Speech language therapists, as communication brokers due to their expertise in facilitating communication, should be at the centre of developing such training programmes. Speech language therapists should also foster collaborations with mental healthcare professionals in clinical spaces when treating persons with communication disorders. What are the potential or actual clinical implications of this work? The lack of knowledge on communication disorders and the subsequent lack of knowledge and skills on appropriate communication strategies to implement when conducting mental healthcare interventions with persons with communication disorders compromises patient care and subjects persons with communication disorders to continuous substandard patient care, which is essentially an infringement on their right to healthcare. It is common knowledge that communication forms the cornerstone of all healthcare interventions, and where there are communication barriers between healthcare providers and their patients, healthcare provision becomes unsuccessful, resulting in negative patient outcomes. The study offers a potential solution to these communication challenges.

The coronavirus disease 2019 (COVID-19) pandemic is having a well-documented impact on the mental health of front-line health and social care workers (HSCWs). However, little attention has been paid to the experiences of, and impact on, the mental health professionals who were rapidly tasked with supporting them. We set out to redress this gap by qualitatively exploring UK mental health professionals' experiences, views and needs while working to support the well-being of front-line HSCWs during the COVID-19 pandemic. Mental health professionals working in roles supporting front-line HSCWs were recruited purposively and interviewed remotely. Transcripts of the interviews were analysed by the research team following the principles of reflexive thematic analysis. We completed interviews with 28 mental health professionals from varied professional backgrounds, career stages and settings across the UK. Mental health professionals were motivated and driven to develop new clinical pathways to support HSCWs they perceived as colleagues and many experienced professional growth. However, this also came at some costs, as they took on additional responsibilities and increased workloads, were anxious and uncertain about how best to support this workforce and tended to neglect their own health and well-being. Many were professionally isolated and were affected vicariously by the traumas and moral injuries that healthcare workers talked about in sessions. This research highlights the urgent need to consider the mental well-being, training and support of mental health professionals who are supporting front-line workers.

While there has been systematic research on the experiences of immigrant patients in mental health services within certain European countries, little research has explored the experiences of mental health professionals in the delivery of services to immigrants across Europe. This study sought to explore professionals' experiences of delivering care to immigrants in districts densely populated with immigrants across Europe. Forty-eight semi-structured interviews were conducted with mental health care professionals working in 16 European countries. Professionals in each country were recruited from three areas with the highest proportion of immigrants. For the purpose of this study, immigrants were defined as first-generation immigrants born outside the country of current residence, including regular immigrants, irregular immigrants, asylum seekers, refugees and victims of human trafficking. Interviews were transcribed and analysed using thematic analysis. The interviews highlighted specific challenges to treating immigrants in mental health services across all 16 countries including complications with diagnosis, difficulty in developing trust and increased risk of marginalisation. Although mental health service delivery varies between and within European countries, consistent challenges exist in the experiences of mental health professionals delivering services in communities with high proportions of immigrants. Improvements to practice should include training in reaching appropriate diagnoses, a focus on building trusting relationships and measures to counter marginalisation.

The objective of the paper is to explore countertransference in qualitative research. Specifically, through the examination of a study which explored the experiences of mental health professionals working with refugee and immigrant families with infants and young children, the paper aims to demonstrate how the monitoring of countertransference can be transformed into a useful research tool. Countertransference movements are examined on multiple levels, in the mental health worker-immigrant/refugee dyad, in the researcher-participant dyad, and at the institutional level. The importance of thinking about a whole research process in terms of the process of countertransference is discussed.

Exposure to suicide is a major factor for suicidality. Mental health professionals and first responders are often exposed to suicide while on-duty. The objective of this scoping review is to describe the state of current research on exposure to suicide among mental health professionals and first responders, focusing on the prevalence and impact of exposure to suicide, and to identify current gaps in the literature. We searched MEDLINE, Scopus, PsychNET, and Web of Science and identified 25 eligible papers. Between 31.5-95.0% of professionals had been exposed to suicide. Exposure to suicide had impacts on personal life, professional life, and mental health; and caused emotional distress. There was little research investigating exposure to suicide among police officers, firefighters, and paramedics. More research existed on mental health professionals, but none assessed exposure to suicide as a risk for suicide amongst this group. The review concludes that exposure to suicide is distressing for mental health professionals, and likely to be for first responder however, more research on these groups, especially paramedics, is required.

Exposure to suicide is a major factor for suicidality. Mental health professionals and first responders are often exposed to suicide while on-duty. The objective of this scoping review is to describe the state of current research on exposure to suicide among mental health professionals and first responders, focusing on the prevalence and impact of exposure to suicide, and to identify current gaps in the literature. We searched MEDLINE, Scopus, PsychNET, and Web of Science and identified 25 eligible papers. Between 31.5–95.0% of professionals had been exposed to suicide. Exposure to suicide had impacts on personal life, professional life, and mental health; and caused emotional distress. There was little research investigating exposure to suicide among police officers, firefighters, and paramedics. More research existed on mental health professionals, but none assessed exposure to suicide as a risk for suicide amongst this group. The review concludes that exposure to suicide is distressing for mental health professionals, and likely to be for first responder however, more research on these groups, especially paramedics, is required.

The use of pro re nata (PRN) medication, a medication that is given when needed, as opposed to medication that is given at a regular time, is surrounded by claims of misuse and poor accountability within the mental health setting. Gaining insight into and understanding of the experiences of health professionals' and patients' use of PRN medication will assist in contributing to improving education and safety around this common intervention. To analyze and synthesize the best available evidence on the perspectives of patients and mental health professionals (MHPs) with their experiences of PRN medication in mental health settings. Participants considered for inclusion in this review include MHPs working in, and adult patients admitted to, an acute adult mental healthcare setting. This review will consider studies that investigated the experience of MHPs' and patients' use of PRN medication in acute adult mental healthcare settings. The current review will consider studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. The context of the review is acute adult mental healthcare settings with no restriction on geographical location. The search strategy aims to find both published and unpublished studies. The databases searched include CINAHL, PubMed, Scopus, PsycINFO and Embase. A gray literature search included ProQuest Dissertations and Theses, Mednar and Google Scholar. Papers selected for retrieval were assessed by two independent reviewers for methodological validity before inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). The standardized data extraction tool from the JBI-QARI was used to extract data from the papers. Qualitative research findings were pooled using the JBI-QARI. This involved the aggregation of findings to generate a set of statements that represented that aggregation, through assembling the findings rated according to their quality and categorizing these findings by similarity in meaning. These categories were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Four studies were included in the systematic review. Two studies each from both groups' perspective. These experiences were combined in one synthesis to look at the issues from mutual perspectives. A total of 40 findings were extracted from these four studies. The findings were grouped into 10 categories and five synthesized findings were developed. Pro re nata medication use among MHPs and service users is subject to many variables from individual decision making to organizational policies. There are many factors that contribute to MHPs prescribing and administering PRN medications and patients had views and opinions on their use of PRN medication in the acute mental health setting.