Community Psychiatric Nurses Research Articles

Profile of community alcohol service users in North Wales

Treating people with alcohol problems can be very expensive. Hospital‐based community focused treatment has been a traditional response. However, treatment for this client group has developed into a very cost effective treatment option. Alcohol is exacting a heavy financial burden upon the limited resources within health care provision (Royal College of Physicians, 2001). The heavy burden placed upon primary care is reflected in the data. General practitioners make the highest number of referrals to the Specialist Alcohol Service (72%). The link to policy is clear with the Welsh Assembly placing greater focus on a condition specific specialist response (Welsh Assembly, 2001). Comparison with patients presenting to a 24‐hour emergency psychiatric assessment service at the district general hospital help define the alcohol service user group. Data confirms that a community‐focused response by specialist community psychiatric nurses is a cost effective and appropriate alternative to hospital admission.

The prevalence of personality disorders, psychotic disorders and affective disorders amongst the patients seen by a community mental health team in London

There is a lack of information regarding the prevalence and co-occurrence of personality disorders, psychotic disorders and affective disorders amongst patients seen by community mental health teams. This study aims to describe the population of patients served by a community mental health team in South London in terms of demographic and clinical characteristics. Computerised hospital records and keyworkers' caseloads were used to identify 193 patients. The Standardised Assessment of Personality was used to assess personality disorders and the Operationalised Criteria Checklist was used to assess psychotic and affective disorders. Fifty-two per cent of patients met the criteria for one or more personality disorders, 67 % of patients had a psychotic illness and 23 % had a diagnosis of a depressive disorder. Community psychiatric nurses (CPNs) mainly saw patients with psychotic illnesses. The non-psychotic patients seen by CPNs had extremely high rates of personality disorder. Patients seen by psychiatrists and psychologists had significantly lower rates of personality disorder. The prevalence of personality disorder is high amongst patients seen by community mental health teams. Possible explanations for this are presented and implications for community care are discussed.

Service contact and psychopathology in very-late-onset schizophrenia-like psychosis: the effects of gender and ethnicity.

Epidemiological data on very-late-onset (>60 years) schizophrenia-like psychosis (SLP) are scarce. There are only two published follow-up studies. To examine the associations of gender and ethnicity with health service contact and psychopathology in SLP. We identified all new referrals of SLP to the Maudsley hospital between 1995-2000. Demographic details and information on the course of the illness were obtained from case notes. Those patients who agreed to take part were seen at home and assessed with respect to psychopathology and neurological side effects. The median duration of illness at the time of assessment was 3 years (range 1-6 years). Male patients were more likely to be admitted to hospital compulsorily and to be lost to follow-up than female patients. Caribbean-born patients were more likely to refuse to take part than British-born patients. Of the 26 (48%) patients who were interviewed, 38% were experiencing paranoid symptoms, 94% of patients receiving medication were in regular contact with a community psychiatric nurse (CPN). Treatment response was dose related and was not increased by the use of a depot. The effects of gender and ethnicity on outcome need to be further investigated through larger studies. High loss to follow-up amongst male patients may be indicative of a poor prognosis. Regular contact with a CPN may be more important than the use of a depot in maintaining treatment response.

Community development: Knowledge, attitudes and training needs amongst professionals in Northern Ireland

Objective To evaluate the level of understanding and the practice of community development among Health and Social Service professionals in Northern Ireland and to assess the potential need for formal training in community development. Design A survey using questionnaires among a representative sample of health and social service professionals in Northern Ireland. Qualitative data was obtained from separate focus groups. Setting Questionnaires were self-completed by subjects contacted at their place of work. Focus groups were carried out by experienced interviewers in workplace settings. Method Ten Health and Social Services Community Trusts were selected to be representative of Trusts in Northern Ireland. Questionnaires were distributed to all 502 Health and Social Service professionals working in these Trusts. A focus group session was carried out in each of four Health and Social Services Community Trusts across the Province. Results The overall response rate was 57 per cent. Two hundred and eighty-seven questionnaires were returned from a total of 502. High response rates were obtained among health visitors, community psychiatric nurses, and social workers for disability, but groups such as community midwives may have been less well represented in our study sample (response rate 21 per cent). Over 28 per cent of subjects, particularly social workers, said they were unfamiliar with the concept of community development. Thirty- nine per cent described their knowledge as adequate and 4 per cent as good. Almost 40 per cent of the subjects said that they never used a document which had been widely distributed in Northern Ireland on a strategy for community development. Seventy-two per cent of subjects had not used the Voluntary Activity Unit's Handbook for Practitioners which had also been widely distributed in the Province. Questions on training required by professionals suggested that the majority of professionals required training in methods and techniques, values and principles, definition and clarification of professional roles, and knowledge of practice elsewhere. Focus groups reported that a high level of commitment and out- of-hours involvement was required to further enhance community development. Conclusions The majority of professional groups were positive about community development, but were unable to find or provide examples. Training needs were identified among all professional groups in this study.

ARTICLE

This article reported on a survey which was designed to measure aspects of community psychiatric nursing (CPN) education in the UK. Thirty-two of the 39 course leaders who ran postqualifying programmes in CPN responded to a nine-page postal questionnaire. Findings indicated that the majority of courses are now run at degree level, and that most appear to include education in key areas of specialist content pertinent to contemporary CPN practice (e.g. collaborative working with service users). Overall, however, the article reported that courses for CPN appeared to be characterized by considerable variation in specialist content. The article concluded by offering possible explanations for this variation and some suggestions for future research.

Gatekeeping access to community mental health teams

Aims and MethodA retrospective survey to explore how consultant psychiatrists, senior house officers and community psychiatric nurses prioritised referrals to four sectorised community mental health teams.ResultsReferral outcomes appeared to be comparable for patients with psychoses, sub-threshold mental health problems and personality disorders. However, differences in the outcomes were apparent for patients with a primary diagnosis of drug/alcohol misuse, as well as for patients with affective disorders and neuroses.Clinical ImplicationsIt may be necessary to establish clearer, consistent boundaries in order to consolidate services for patients with severe mental health problems.

Risk assessment for people with mental health problems: a pilot study of reliability in working practice

INTRODUCTION : This paper describes a pilot study of reliability in the risk assessment of people with mental health problems. Specifically, we explore the evidence for professional and gender bias in ratings, in addition to the general level of agreement between raters. METHOD : Six professional groups (psychiatrists, junior psychiatric doctors, nurses, community psychiatric nurses, social workers and occupational therapists) participated in the study and rated 159 patients on a nine-item scale which assessed different components of risk. RESULTS : Contrary to some earlier work, we found no clear evidence that any one group consistently rated more extremely than any other group. Women were more cautious than men in their ratings, and this concurs with previous studies. Finally, a reliability study of randomly selected pairs of raters showed only moderate levels of agreement and, in some instances, the levels of disagreement were high enough to warrant concern. CONCLUSION : These findings are discussed in the context of current risk assessment practice and the problems associated with investigating reliability in naturalistic settings and designing appropriate rating tools for risk. (Int J Psych Clin Pract 2002; 6: 73-81)

Closer working with primary care is associated with a sharp increase in referrals to community mental health services

Objectives :To study the effect of establishing closer links with general practitioners on referrals to community mental health teams and to discuss implications of the findings for implementing standards 2 and 4 of the National Service Framework for Mental Health. Design : Cohort study. Setting : Plymouth inner city mental health services. Main outcome measures : Numbers of referrals to the community mental health teams, the emergency psychiatric service and acute psychiatric admissions in the 12 months before and after services were reconfigured to provide closer working arrangements with primary care. Results : There was an approximately three-fold increase in referrals to the community teams following reconfiguration, but no significant difference in the number of emergency referrals or the numbers admitted. Conclusions : Linking community psychiatric nurses with primary care increased demand for secondary mental health services. Clear referral guidelines and shared care protocols should be in place before service change is implemented. implications in the light of increased workload for staff carrying out more assessments. There are also resource

A randomized controlled trial of problem solving for anxiety, depression and life difficulties by community psychiatric nurses among general practice patients: background and method

It is not clear whether treatment for anxiety, depression and life difficulties by community psychiatric nurses in primary care is effective or cost-effective. Community psychiatric nurses are asked to focus their attention on patients with a diagnosis of severe and enduring mental health problems. The one previous study of community psychiatric nurses in primary care found no difference in outcome at 6 months, but patients with community psychiatric nurse care had fewer days off work over the study period. Problem solving by general practitioners (GPs) and community nurses has been shown to be effective for emotional disorders and depression in primary care. Treatment by community psychiatric nurses may have advantages in that it could reduce GP time and prescribing. Patients may prefer community psychiatric nurse care to psychiatric referral and community psychiatric nurses may prefer mixed case loads. This study was designed in order to inform policy on this issue. This paper describes the design of a randomized controlled trial and economic evaluation comparing community psychiatric nurse problem-solving treatment, generic community psychiatric nurse care and usual GP care for patients with anxiety, depression and life difficulties. If referral to community psychiatric nurses proves not to be effective or cost-effective GPs should be advised against referring patients with these types of problems. If community psychiatric nurse intervention is more effective and cost effective than GP treatment then models of care appropriate for delivering in primary care should be considered.

Caring for a relative with dementia: The perceptions of carers and CPNs

Older people with dementia living in the community are most likely to be cared for by other older people, predominantly spouses, who will be at increased risk of stress‐related health problems themselves. Appropriate support of such carers is crucial if carer breakdown and consequent care‐receiver admission to residential homes is to be avoided. This paper examines the experience of older carers of frail older people with dementia and examines the kind of support that is provided to such carers. In practice, the sole source of professional support received by older people in this study was from community psychiatric nurses (CPNs). CPNs' role did not comprise hands‐on care‐giving and family carers carried out most personal/physical and healthcare tasks themselves, aided in some cases by care workers. The paper concludes by suggesting that lack of support for carers in these activities requires redress.

A survey of psychiatrists' and nurses' views of mental health advocacy

Aims and MethodAdvocacy is assuming an increasingly important role in the delivery of mental health services, but many psychiatrists feel threatened by it. This study was performed to ascertain how much doctors and nurses know about advocacy and their attitudes towards it. We interviewed five senior house officers, five staff nurses and four community psychiatric nurses (CPNs) to examine their understanding, experience and opinions about advocacy. A full-time advocate was also interviewed to establish his views about how well staff understood his role.ResultsIn general there was poor understanding of the background and training of advocates, and their Code of Practice. There were also important differences in the way in which different groups of staff saw advocacy, with CPNs having the best understanding. Experiences of advocacy were positive and it was seen as being helpful both for clients and staff, despite fears that advocates might work to their ‘own agendas'.Clinical ImplicationsThere is a need to improve psychiatrists' understanding of what advocacy is, through the involvement of advocates and service users in their training. This would help to allay their anxieties about the role of advocates.

A stepwise multivariate analysis of factors that contribute to stress for mental health nurses working in the community.

The aim of the study was to examine the variety, frequency and severity of stressors experienced by community mental health nurses (CMHNs) in Wales. Numerous studies undertaken throughout the United Kingdom (UK) have indicated that those health professionals working as part of community teams are experiencing increasing levels of stress and burnout. Sample sizes have tended to be small and participants have been drawn mainly from sites in England. A questionnaire booklet, which included a number of validated measures, was distributed to 614 CMHNs. These included Maslach Human Services Survey, Community Psychiatric Nursing (CPN) Stress Questionnaire, PsychNurse Coping Questionnaire, Rosenberg Self-Esteem Scale and General Health Questionnaire GHQ-12. The study was the largest of its kind conducted in the UK. Data were collected from 301 CMHNs, representing a response rate of 49%. Community mental health nurses identified the most stressful issues as trying to maintain a good quality service in the midst of long waiting lists and poor resources and having too many interruptions while trying to work in the office. The best demographic predictors of high stress scores were having an unsupportive line manager, working with a specific client group and not having job security. These factors accounted for 20% of the variance in the total stress score. When the results from the psychometric instruments were included, 46% of the variance in the total stress score was accounted for. The predictive variables were emotional exhaustion, working with a specific client group, job security and alcohol consumption. These findings indicate that there is a need to create more supportive environments both in terms of job security and management support, especially for those working in the fields of severe mental illness and rehabilitation.

This issue of JAN

This issue of <i>JAN</i>

The social construction of risk by community psychiatric nurses and family carers for people with dementia

This paper examines the conversational and discursive processes through which situations are constructed as a risk by informal carers and community psychiatric nurses working with people who have dementia. The data were taken from 24 tape recordings of domiciliary meetings between primary informal carers for people with dementia and their community psychiatric nurse (CPN). Data were analysed using techniques developed from conversation analysis and discourse analysis. The analysis identifies four stages associated with the construction of risk by informal carers and CPNs. These stages are fully discussed in relation to the provision of care.

Attitudes toward suicide prevention in front-line health staff.

A questionnaire assessing attitudes toward suicide prevention was constructed and shown to have satisfactory reliability and internal consistency. The determinants and distribution of these attitudes were investigated in four groups of health professionals who are in contact with suicidal patients: general practitioners, accident and emergency nurses, psychiatrists in training, and community psychiatric nurses. Attitudes toward suicide prevention were shown to differ significantly between professional groups. More positive attitudes were associated with mental health professionals, working in the community, and previous training in suicide risk assessment. Negative attitudes should be assessed and targeted in training designed to improve the management of suicide risk.

The relationship between community psychiatric nurses and clients with severe and persistent mental illness: the client's experience.

The aim of this phenomenological study was to construct an interpretation of the experience of nurse-patient relationships, in the context of community psychiatric nursing. The purpose of this paper is to focus on the experience of the relationship from the perspective of the clients. Themes of 'having someone looking out for me', 'working in collaboration', and 'being understood and gaining understanding' were identified. This thematic structure was used to understand the meaning of the relationship for the clients. Implications for practice, education, clinical supervision and mental health services are discussed.

Nurses are reluctant to take on prescribing role

Community psychiatric nurses want training to be built into degrees or diplomas

The use of outcome measures to evaluate the efficacy and tolerability of antipsychotic medication: a comparison of Thorn graduate and CPN practice.

Assessing the tolerability and efficacy of treatment with antipsychotic medication is a vital part of mental health care. Research has suggested that many side-effects go undetected by clinicians and there is a need to use standardized assessment tools to ensure that treatments are comprehensively evaluated. The training of Community Psychiatric Nurses (CPNs), who provide much of patients' care, should focus on enhancing skills in using such assessments. This study aimed to examine differences in the use of standardized assessments of antipsychotic side-effects and psychopathology by CPNs and Thorn graduates who had received additional training in delivering psychosocial interventions. A questionnaire was sent to 240 Thorn graduates and CPNs practising in England, with an overall adjusted response rate of 54%. Thorn graduates reported using significantly more standardized assessments of side-effects and psychopathology than CPNs. A trend in both groups towards the use of measures that relied on patient self-report of side-effects was observed. This study identified important deficiencies in current CPN practice. A programme of targeted training may be a more realistic and efficient method of enhancing medication management practices in large numbers of CPNs compared to the more expensive and time-consuming Thorn programme.

The relationship between support and stress in forensic community mental health nursing.

AIMS OF THE STUDY/PAPER: This paper reports the results of a survey of forensic community mental health nurses (FCMHNs) in England and Wales which aimed to ascertain the level of stress and burnout experienced by this group. Several studies have identified that mental health nursing is a stressful activity and the relationship between factors such as age, experience, support, caseload size and perceived stress have been explored. However, until recently, no studies have examined the situation of FCMHNs and this paper extends the analysis of studies completed by the main author, considering issues related to coping abilities and support systems. The survey involved respondents completing a demographic questionnaire and a range of standardized validated measures (Maslach Burnout Inventory, General Health Questionnaire and Community Psychiatric Nurse Stress Questionnaire). The population for the study was all identified FCMHNs attached to the 26 National Health Service (NHS) Medium Secure Units in England and Wales (n=104). A high response rate of 77% (n=80) was achieved. The results identified that a number of respondents were experiencing burnout. Statistically significant associations were found between caseload size and level of stress. The results also suggest that support from managers and colleagues were an important factor in ameliorating the experience of stress and show that individuals in this study experiencing high levels of stress adopted palliative behaviours such as use of alcohol. The paper concludes by suggesting that such findings should be considered when delivering stress management programmes and reinforce the potential benefit of effective clinical supervision as a means of staff support.

The conversational and discursive construction of community psychiatric nursing for chronically confused people and their families.

The paper examines the conversational and discursive processes that occur within domiciliary visits between community psychiatric nurses (CPNs) and relatives of chronically confused people. Three conversation formats are identified, through which talk between CPNs and carers is organised. In addition, various discursive practices are also identified within domiciliary meetings. The contribution of these conversational and discursive features to the work of CPNs is fully discussed in relation to what they accomplish within the visit. The data comprised 48 paired tape recordings. Of these recordings, 24 were unstructured interviews between CPNs and informal carers to people who had been diagnosed as having dementia by a medical practitioner. In addition, 24 domiciliary meetings between primary informal carers and their CPNs were tape recorded and fully transcribed. The transcripts were analysed using techniques drawn from conversation analysis and discourse analysis. The implications of the findings upon CPN practice are examined.