Community Psychiatric Nurses Research Articles

Role of the community psychiatric nurse in the management of schizophrenia

This paper will describe the increasingly important role of the community psychiatric nurse (CPN) in the treatment and management of people with schizophrenia, and draw attention to new training programmes which have a focus on skills acquisition in evidence-based methods. However, before describing the way in which these programmes of training improve CPN skills, it is worth examining the history of community psychiatric nursing.

Service use and costs of people with dual diagnosis in South London

To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse. Patients with psychosis were identified and a representative sample were interviewed. Six-month service use was measured and costs calculated. Regression models were developed to predict costs from background characteristics and dual diagnosis status. A greater proportion of the patients with dual diagnosis used community psychiatric nurses, in-patient care and the emergency clinic. The regression analysis revealed that dual diagnosis patients had significantly higher 'core' psychiatric service costs (a difference of pound sterling 1362) and non-accommodation service costs (pound sterling 1360) than non-dual-diagnosis patients. The difference when all services were analysed was pound sterling 1046, but this was not statistically significant. Specific interventions for dual diagnosis patients should be introduced and assessed in terms of individual outcomes, service use and costs.

The Experience of Caregiving Inventory: further evidence.

The aim of this study was to reexamine the construct validity of the Experience of Caregiving Inventory (ECI) using new, independent data from a population of patients and their carers. This involved re-testing the ECI within the stress-coping model, but adding new variables which included independently rated (rather than carer-rated) assessments of the patient's symptoms and disabilities, a rating of social support (this time for the patient rather than the carer) and a measure of a range of service inputs. Data were available on 69 patients and their carers from the PRiSM Psychosis Study. Two regression analyses were performed; the first to establish the extent to which the ECI predicted GHQ scores and the second to examine predictors of the ECI selected from the wider dataset on the basis of their likely relationship to carer appraisal. The second regression analysis was performed in two stages, allowing the effect of service factors to be assessed after controlling for the impact of patient personal characteristics such as illness-related or environmental factors. ECI scores accounted for 27% of the variance of GHQ scores. Over one-third of the ECI negative appraisal can be explained by a combination of patient disability (the Social Behaviour Score Total), extent of patients' social network (Social Network Schedule: Number of Friends) and involvement of a Community Psychiatric Nurse (CPN). At the same level of patient morbidity and informal social network, CPN contact reduced ECI scores. As hypothesised, ECI scores correlated significantly with the other measures in the directions predicted by the stress-coping model; that is, negative caregiving as measured by the ECI predicted carer morbidity, while it in turn was predicted by a combination of stressor variables (patient symptoms and disability) acting to increase it, and mediating variables (social support, service inputs) acting to reduce it. Implications for services are discussed.

Predictive medicine, genetics and schizophrenia

One of the developments frequently foreseen as an outcome of the human genome project is 'predictive medicine'. This is usually taken to mean identification of individuals with genetic risk factors for disease, followed by preventive measures. The paper examines the complications that may arise in efforts to realize this vision in relation to a particular condition often mentioned as a target for the new genetics: schizophrenia. This examination is informed by interviews with six groups with different interests in and experiences of schizophrenia: geneticists, psychiatrists, community psychiatric nurses, general practitioners, carers and schizophrenic patients. It is concluded that predicting who may be at increased risk of schizophrenia will be, at best, a mixed blessing for more of those involved. Questions of quilt, stigma and labelling will be particularly troubling if genes of major effect in the aetiology of schizophrenia are identified.

Cost-effectiveness analysis of case management versus a routine community care organization for patients with chronic schizophrenia

This article reports the economic analysis of a study on the implementation of case management in the Community Psychiatric Nursing Service (CPNS) caring for chronic schizophrenic clients in Hong Kong. The purpose of the study was to compare the outcome of case management service with the conventional practice CPNS. Sixty-two subjects participated in the analysis. Cost-effectiveness analysis showed that case management costs more in Hong Kong $3,600 (US$450) per person and that over a 5-month period, case management was associated with improvements in psychological and functional outcomes and patient satisfaction. The results of this study will inform policy makers about resource allocation and policy development in the implementation of case management for the care of mentally ill clients.

An explanation of the coping strategies used by Community Psychiatric Nurses in Wales

Abstract Six hundred and fourteen Community Psychiatric Nurses (CPNs) were surveyed to estimate the extent to which they used various coping strategies in order to reduce occupation‐related stress. A questionnaire booklet, which included a number of validated measures and the Psychnurse methods of coping questionnaire, were used. ‘Having a stable home life that was separate from work’ and ‘knowing that my life outside of work is healthy, enjoyable and worthwhile’ were methods used most in order to cope with work‐based stress. ‘Through having team supervision’ and ‘by having confidential one to one supervision’ were the methods used the least. The mean overall coping scores were significantly higher for females and those who felt that they had job security. Those people who scored higher on the coping test instrument were significantly more likely to be older and have worked within the field of community mental health for longer. The current drive towards clinical supervision promoted through policy initiatives, appears not to be supported by these findings. The implications for CPN services and for further study are highlighted.

Health professionals' views of services for schizophrenia – fragmentation and inequality

There has been much debate about effective treatments, service configurations and costs within Britain's mental health care system, but it has largely taken place in academic and management circles. We were interested in the views of those providing care. We organised a meeting of community psychiatric nurses, general practitioners and consultant psychiatrists (funded with an educational grant from Zeneca Pharmaceuticals). Participants worked in various parts of Great Britain, including rural and inner city areas. The authors facilitated the discussion, the emphasis of which was on participants' clinical experience.

Reviewing the literature constructing the field: Accounting for the CPN in practice and research

Making health practice and policy 'evidence-based' politicises clinical research, by making proof of 'effectiveness' the key to resources. In this paper we revisit a literature review of clinical effectiveness in psychiatric nursing in order to demonstrate how, in a multi-professional health system, scientific publications can also function as claims in the competition for resources. We consider the rhetorical dimension both of the literature reviewed, and of the act of literaturereviewing itself. Each genre comprising 'the literature' constructs a version of the field of mental health care and a version of the CPN within the field. Each genre thereby constructs 'effectiveness' differently. We therefore recast the problem of determining the effectiveness of Community Psychiatric Nurses (CPNs) as the problem of determining how the problem of CPN effectiveness is constructed as a problem in different discursive contexts, i.e. by different professional and non-professional discourse communities. In reconstructing the problem of effectiveness as one part of the wider struggle for definition of the field of mental health care, the genres we consider are: • care studies, in which CPNs report on their own work; • qualitative studies related to CPN effectiveness; • users' reports on their mental health experiences; • the 'hidden CPN'- loss of information in studies of services; • the 'disappearing CPN'- loss of role specificity in community psychiatric projects. Concluding with a case study of the literature as political remote control (negotiating the CPN as a resource in community mental health care), we show how, if the field can be seen as a field of interests, sometimes openly displayed, sometimes not, a basic game being played in the literature is that of differently placed social groups seeking control of mental health services in the community through the production of legitimating accounts of practice.

The morality of treating patients with depot neuroleptics: the experience of community psychiatric nurses.

The aim of this qualitative study was to gain an understanding of the meaning that community psychiatric nurses impart to their everyday interactions with patients in depot neuroleptic treatment situations. Nine experienced community psychiatric nurses were interviewed using semistructured, open-ended questions. Data analysis was by the phenomenological descriptive method according to Giorgi. Four themes were identified, highlighting aspects of the moral meaning of treating patients with depot neuroleptics: (1) 'benevolent justification' occurs when nurses perceive that the patient's welfare is at stake; (2) 'inability to advocate the patients' best interest' occurs when nurses feel they are at a disadvantage; (3) 'accommodative interactions' occur when nurses are able to respond to a patient's expressed needs; and (4) 'acceptable advocacy' occurs when physicians are sensitive to nurses' suggestions on patients' treatment. The findings indicate that treatment care planning involving both patients and nurses is essential to enhance patients' autonomy, which is a precondition for satisfactory interactions. This phenomenological study describes the meaning that nurses give to administering depot neuroleptic injections to patients in the context of community psychiatric clinics. The phenomenon of concern was identified as the moral aspect in the interactions with individual patients in the treatment situation.

Mental health in the community: roles, responsibilities and organisation of primary care and specialist services

UK health policy embodies two opposing trends affecting mental health care in the community: a move towards a primary care-led NHS which inevitably reflects the concern of GPs with 'milder' mental illness, and specific mental health policies intended to refocus the specialist services on people with 'serious' mental illness. A training needs assessment study undertaken with primary care staff and community psychiatric nurses revealed the problems created on the ground by these opposing trends. This paper describes these problems from the perspectives of three groups: primary care nurses, general practitioners (GPs) and community psychiatric nurses (CPNs). The overall impression was of primary care teams encountering high levels of need for which they felt unprepared, and of a CPN service torn in two by the opposing demands of GPs and their employing trust. The discussion section of the paper compares the findings of the study with a model for reorganisation put forward in the literature and highlights the obstacles to be overcome in bridging the policy gap.

How urgent is urgent? Analysing urgent out-patient referrals to an adult psychiatric service

INTRODUCTION: It was noticed that over some years the number of referrals to the outpatient clinic (from various sources) which were marked 'urgent' had increased. We aimed to examine who makes these urgent referrals and the clinical factors associated with 'urgent' status. METHODS: A sample of 201 referrals over a 26-month period was examined. Details of the referral requests were collected using a specially designed form. After each 'urgent' assessment, the referral was scored for appropriateness. This gave an indication of the agreement between referrer and clinic doctor as to what should constitute an ¤ urgent' referral. RESULTS: The majority of urgent referrals were from community psychiatric nurses, who, together with psychiatric social workers, make the most appropriate referrals. The more appropriate referrals clearly specified the clinical factors associated with urgent need for review. Patients regarded as suicidal were not associated with significantly higher appropriateness scores. CONCLUSION: Referrers should try and make 'urgent' outpatient requests as specific as possible: more clinical detail gives a clearer picture to the clinic doctor. Telephone consultations with general practitioners may help to ascertain a clearer picture of urgent requests if detail is lacking. Health professionals may all benefit from education in suicidal risk assessment. ( Int J Psych Clin Pract 2000; 4: 233 - 235)

The Consultancy Liaison Addiction Service - the first 5 years of an integrated, primary care-based community drug and alcohol team

Government policy, running through the 10-Year Drug Strategy, Tackling Drugs to Build a Better Britain (The Stationery Office, 1998) and the New Drug Misuse Clinical Guidelines (Department of Health, The Scottish Office, 1999) highlights the need for health authorities and now PCGs to invest in shared care mechanisms to support primary care in its task of caring for drug misusers. Primary Care Trusts, as freestanding NHS organizations, will in time be able to commission, purchase and provide these services themselves, using primary care expertise alongside specialists. This paper describes a model of primary care-based shared care service, the Consultancy Liaison Addiction Service, that has been in operation for 5 years in South London, that predates these changes in the NHS yet could be considered by PCGs or PCTs when planning services for drug misusers. The service comprises a team of drug and alcohol community psychiatric nurses, supported and managed by a principal in general practice. Together they have worked with 72 neighbouring general practices, supporting the treatment of alcohol-misusing and drug-misusing patients. The team has a separate identity from, but is closely integrated into the secondary specialist addiction service producing effective continuum of care.

The Morality of Treating Patients with Depot Neuroleptics: the experience of community psychiatric nurses

The Morality of Treating Patients with Depot Neuroleptics: the experience of community psychiatric nurses

Can a standardized needs assessment be used to improve the care of people with severe mental disorders? A pilot study of 'needs feedback'.

The care programme approach (CPA) was introduced in the United Kingdom in 1991 to ensure that the needs of people with mental health problems are met appropriately. Many community psychiatric nurses (CPNs) act as 'key workers' under the CPA. Recent evidence suggests that the CPA is not particularly effective at meeting the needs of this vulnerable group, but it might be possible to enhance the CPA by introducing a more 'needs-led' approach to the planning of nursing care. 'Needs feedback' is a technique for enhancing the CPA. Needs feedback begins with a standardized assessment of patients' psychiatric and social needs by a nurse specialist. The patient's CPN is then provided with information on: (a) the needs identified; (b) why these needs have been identified; (c) the interventions required to meet the identified needs; and (d) how these interventions may be obtained. In the pilot study reported in this paper, 20 patients with severe mental disorder were evaluated before and after their CPN received needs feedback. All patients were living in the community and being managed by CPNs under the CPA. Outcome was assessed 6 months after the feedback in terms of: mental state, social behaviour and number of 'unmet' needs. Needs feedback was found to be compatible with the CPA in that it proved acceptable to CPNs and patients. Significant improvements were seen in the number of 'unmet' needs and the level of anxious/depressive symptoms. Improvements approaching significance were seen for social functioning and negative psychiatric symptoms, but not for positive psychiatric symptoms. This pilot study suggests that needs feedback may improve the quality of nursing assessment and care planning within the CPA. Further controlled investigations of needs feedback are justified.

General practitioners' perceptions of community psychiatric nurses in primary care.

The management of and responsibility for the care of people with mental health problems in the community is increasingly being assumed by general practitioners (GPs) and primary care personnel. As primary care groups (PCGs) evolve, so must their expertise in managing people with a wide range of mental health problems. It is expected that all mental health professionals will participate in this development, although it is likely that community psychiatric nurses (CPNs) will be the largest professional group involved, with a significant part to play in the shaping, management and delivery of mental health services. To date, there has been little research into how CPNs are perceived by other primary health care professionals. This study seeks to provide an insight into how GPs assess the contribution of CPNs in primary care. Overall, the results of the study suggest that GPs view CPNs favourably and consider that they have an important role to play. Greater involvement in primary care raises issues about the education and preparation of CPNs, their professional development and supervision needs.

Depot neuroleptics, schizophrenia and the role of the nurse: is practice evidence based? A review of the literature.

Nurses are expected to justify their practice with research based evidence. Community psychiatric nurses (CPNs) are under pressure to concentrate more on the 'seriously mentally ill', particularly those with a diagnosis of schizophrenia. Neuroleptic medicines are a recommended therapy in schizophrenia. The administration and monitoring of these drugs is a central part of the CPN's role. The CPN also often assumes an important position as patient advocate in relation to prescribing practices. Neuroleptics are commonly given in depot form to promote compliance, prevent relapse and be of benefit to the patient. This literature review considers the research evidence that these aims are achieved through current practice and reflects on the implications for nursing. In the absence of definitive research work, it may be that important decisions are based on received wisdom rather than research evidence. Whilst the data supporting the use of depots are inconclusive, there is an increasing body of knowledge demonstrating the efficacy of nursing approaches to drug therapy which seek to empower the patient.

Testing headings for communicating the personal health record: comparison from the recipients’ perspective

In the spring of 1998, 16 general practitioners and 16 community psychiatric nurses participated in a study to test a draft set of headings for communicating clinical summaries. Eight anonymized psychiatric discharge summaries were used to assess the impact of the presentational format on the time taken by professionals to read the summaries and to answer a series of standard questions about each of them. Respondents also completed a questionnaire on their opinions of the headings. There was considerable variation between individuals in the times taken to read the summaries and answer the questions, but no evidence that any of the formats was associated with decreased reading time or with improvement in retrieving information. Most respondents preferred information structured using the headings rather than the original semi-structured discharge summaries, and information on paper rather than on computer screen. Respondents were guardedly supportive of the particular draft headings presented. A weak preference was expressed for locally defined headings, with some recognition of advantages in widely agreed headings. There was a view that there were too many headings, and there was overlap between specific heading pairs (for example, ‘aim’ and ‘goal’). Concerns were expressed about specific headings, particularly the ‘softer’ headings, such as ‘informing’ and ‘communicating’.

Reflective narrative and dementia care.

This study was an enquiry into how clinical supervision could enable a team of six community psychiatric nurses to provide improved patient-centred care. It also examined how feelings of burn-out, stress and tedium when caring for people with dementia could be relieved. The methodology used in the study analysed the process, enabling the findings to be studied. This is new paradigm research, requiring the researcher and participants to be equal and active coenquirers into the process facilitating the enquiry. Six community psychiatric nurses allowed their period of supervision to be recorded over six months in order to identify relevant issues of concern and resolution in their practice. It was anticipated that the experiences revealed during supervision would provide a means by which the nurses could develop their skill and knowledge and improve their care-giving. The findings suggest that the education of community psychiatric nurses needs to enable them to develop the ability to demonstrate emotional competence and to carry out self-questioning.

How informed are community psychiatric nurses (CPNs) of their role in the implementation of supervised discharge?

A questionnaire was delivered to community psychiatric nurses (CPNs) (n = 23) in order to determine whether they had received adequate training in relation to the 1995 Mental Health (Patients in the Community) Act. Data collected were analyzed. The findings suggest that there is a lack of knowledge in relation to the documentation. The research suggests that more formal training in relation to policy documents should be provided by employers.

An investigation into community psychiatric nurses' use of humour during client interactions.

Community psychiatric nurses' (CPNs') accounts of interactions with clients often reflect benefits of using humour appropriately. This is despite the use of humour as a specific therapeutic form of communication generally being ignored during CPNs' professional development. With the growth in community care, mental health nurses are required to function more autonomously within the client's home environment, thus the contextual nature of the nurse's use of humour may have to be adjusted accordingly. How nurses makes this adjustment of their use of humour appears to be left to their own experiences. Yet inappropriate use of humour may be costly to the nurse-client relationship. The research described in this paper used a descriptive qualitative methodology to explore the perceptions of seven CPNs working in Scotland in relation to their use of humour during client interactions. As this study did not specifically access clients, ethical permission was not required from the local research and ethics committee. This did not excuse the author from recognizing ethical considerations of the subjects in relation to sharing information about being volunteers, their rights of withdrawal and the risks and benefits of the study. Confidentiality and anonymity were also maintained by the use of pseudonyms. Data collected through critical incident analysis and interviews were subjected to content analysis. Findings confirm the paradoxical nature of humour. Humour, when used appropriately, assisted the development of trust and changing the client's restrictive perceptions. Damaging effects were reported, however, if the humour was misinterpreted or perceived by the client as demeaning their experience. Although the CPNs had not received any formal education about the use of humour, recommendations centred on raising student nurses' and CPNs' awareness about their own use of humour.