Mental health nurses establishing psychosocial interventions within acute inpatient settings
Antony Mullen, RN, BN, MN, FACMHN
Antony Mullen, Lake Macquarie Mental Health Service, Hunter New England Area Health Service, PO Box 833, Newcastle NSW 2300, Australia. Email: firstname.lastname@example.org
Acute inpatient units provide care for the most acutely unwell people experiencing a mental illness. As a result, the focus for care is on the containment of difficult behaviour and the management of those considered to be ‘at high risk’ of harm. Subsequently, recovery-based philosophies are being eroded, and psychosocial interventions are not being provided. Despite the pivotal role that mental health nurses play in the treatment process in the acute inpatient setting, a review of the literature indicates that mental health nursing practice is too custodial, and essentially operates within an observational framework without actively providing psychosocial interventions. This paper will discuss the problems with mental health nursing practice in acute inpatient units highlighted in the current literature. It will then put forward the argument for routine use of psychosocial interventions as a means of addressing some of these problems.
There is no doubt that acute inpatient units are challenging environments to work in. They are extremely busy, high-pressured environments that deal with complex mental health issues. They also are expected to deal with high bed occupancy rates, high patient turnover, and short length of stays (Bowles 2000; Cleary 2003; Cleary 2004; Higgins et al. 1999; Hurst et al. 1998; Mistral et al. 2002). These reasons are used to explain why mental health nurses find it difficult to provide evidence-based psychosocial interventions in acute inpatient units (Happell et al. 2002). Psychosocial interventions include such strategies as stress management, self-coping skills, relapse prevention, and psychoeducation. They also include psychological therapies, such as cognitive behavioural strategies or motivational interviewing techniques. A lack of skills and knowledge in these interventions has also been used to explain this situation (Baker 2000; Bowles 2000; Cleary et al. 2005; Gournay 1995; Gournay et al. 1998). However, mental health nurses report that there is no time to engage in these activities (Happell et al. 2002). On the contrary, the more chaotic and busy the environment, the greater the need to ensure that structured and proactive interventions are provided.
Recently, a study in the UK attempted to outline the purpose of acute inpatient units. Essentially, the function of these units was to provide assessment of mental health problems, management and care coordination, keep the patient safe, meet basic health needs, and provide effective treatment (Bowers et al. 2005a). In another inquiry, Bowers (2005) specified the roles of mental health nurses within acute inpatient units: to collect and communicate information, give and monitor treatment, tolerate and manage disturbed behaviour, provide personal care, and manage the environment.
On this basis, the provision of treatment is an agreed function of acute inpatient mental health units and alegitimate role for mental health nurses. Yet a vital part of treatment, in the form of psychosocial interventions, is not being provided. Another reason for this is that patients in acute inpatient mental health units are regarded as being ‘too unwell’, and therefore, lack the necessary insight to benefit from psychosocial interventions. Despite this argument, authors have suggested that acute inpatient units are indeed highly suitable places for psychosocial interventions to be provided (Baker 2000; McGann & Bowers 2005).
Risk assessment and observation are the main strategies used to maintain patient safety within inpatient units (Barker & Cutliffe 1999; Bowles 2000; Bowles et al. 2002). There is an increasing trend towards managing the risk by hospitalization itself, without also utilizing structured therapeutic interventions (Bowles 2000). In other words, there is no expectation to proactively engage clients in psychosocial interventions as a means of managing the risk.
The literature identifies a number of problems with mental health nursing practice in inpatient settings. In the present study, this literature is reviewed, and an argument for the establishment of psychosocial interventions as a partial solution to this situation is articulated.
METHOD OF LITERATURE REVIEW
The CINAHL and MEDLINE databases were searched, initially using general terms ‘acute inpatient mental health units’ and ‘mental health nursing’, in order to identify review or discussion articles. A number of key review articles were produced from this initial search and articulated certain problems with mental health nursing practice within acute inpatient units. Influential authors were also identified through perusing the reference lists from these review articles. Those authors were in turn searched separately. Areas of practice and key terms began to emerge, such as ‘custodial care’, ‘reactive practice’, and ‘observation culture’, and these were further searched as keywords in the same databases. The final list of problems generated were the most cited practice issues in the literature. The majority of articles reviewed were discussion papers or qualitative studies of mental health nursing practice. There is very little in the current literature that reports empirical findings or measures the outcomes of implementing psychosocial interventions in acute inpatient settings.
PROBLEMS WITH MENTAL HEALTH NURSING PRACTICE IN ACUTE INPATIENT SETTINGS
Reduced patient interaction
The amount of time nurses spend in meaningful face-to-face interactions has declined. Talking to patients seems to have been replaced by observing patients. Furthermore, time spent in the nurse's office or time involved in paperwork and administrative duties is discussed as contributing to this situation (Bowers et al. 2005a; Bowles 2000; Higgins et al. 1999; Hurst et al. 1998).
The trend towards observing and monitoring patients, rather than interacting and engaging with them, is also discussed in the literature and is referred to as the ‘observation culture’ (Barker & Cutliffe 1999; Bowles 2000; Bowles et al. 2002). Policies appear to have reinforced an over reliance on risk status and how often a patient is observed and ‘checked’, rather than an understanding of what is happening for the patient. The ongoing need to engage, assess, and interact is therefore negated because nurses inadvertently believe they already have the necessary information to provide care.
Defensive and reactive practice
Related to an ‘observation culture’, mental health nurses have fallen into a defensive mode of practice, where time is spent reacting to situations, rather than being proactive in planning individualized nursing interventions. It is thought that mental health nurses have become psychologically withdrawn from patient interactions (Bowles 2000; Fourie et al. 2005; Higgins et al. 1999). This may be the by-product of working within acute inpatient environments and an attempt to protect oneself from burnout, or be the result of burnout itself.
Focus on risk management and observation protocols
Close observation protocols are a widely accepted method of managing those patients deemed to be at risk (Cleary et al. 1999) Some have questioned the rationale and/or effectiveness of such protocols (Bertram & Stickley 2005; Bowers et al. 2005a; Bowles 2000; Bowles et al. 2002). For example, do they merely give the appearance of keeping patients safe or are they a valid intervention? Furthermore, patients have reported the experience of continuous observation as being degrading and humiliating (Bowles et al. 2002). A focus on risk as the primary problem potentially leads care away from the treatment of symptoms and the underlying condition. Surely the emphasis is best placed on equipping the person with the skills to manage distress in order to overcome future situations where they may be at risk, rather than merely focusing on the risk itself. In other words, a skills approach for managing risk that aims to develop an autonomous approach aimed at prevention and self management.
Overemphasis on medication
While medication is an important part of treatment, it would seem that it has become the default approach in situations where other interventions could be used either alone or in conjunction (Bowles 2000; O'Brien & Cole 2004). Where mental health nurses are most open to this criticism is in the use of PRN, or as needed, medication; for example, giving benzodiazepine medication for insomnia or agitation, without exploring sleep hygiene strategies, relaxation or breathing exercises, or other forms of distraction. Authors have suggested that the indication for PRN is when other less invasive interventions have failed, rather than being a first-line intervention (Usher & Luck 2004). Furthermore, the progress of a patient can be measured by the amount of PRN medication that is being used during a given period. It is a concern for nursing practice if patient outcomes are being measured in such a way. This is particularly concerning when you consider that the documentation surrounding the rationale for PRN medication and the effect is often unclear (Curtis & Capp 2003).
The emerging evidence to support the delivery of cognitive behaviour therapy (CBT) within acute inpatient settings for psychotic disorders provides an interesting opportunity for mental health nurses to balance the use of PRN medication for psychotic symptoms. Specifically, this evidence centres on faster remission rates and reductions in positive symptoms (Drury et al. 1996a,b; Haddock et al. 1999; Lewis et al. 2002; Startup et al. 2004). It is crucial that the appropriate training and supervision be provided if mental health nurses are to utilize such strategies. Nonetheless, mental health nurses can support the CBT framework in managing psychotic symptoms in collaboration with other expert clinicians.
Current practice has been criticized for being overly custodial, where patients are largely supervised by nurses in a similar way that prisoners are watched by prison officers. Furthermore, being overly controlling or paternal, or where strict limit setting measures are used regularly, are also features of custodial approaches to care cited in the literature (Alexander & Bowers 2004; Bertram & Stickley 2005). Authors have highlighted problems with punitive responses and the risk of reinforcing dysfunctional behaviour. This is widely viewed as a counterproductive approach, where the denial of patient requests has been linked with violence, and the imposing of restrictions with absconding (Bertram & Stickley 2005; Bowers et al. 2005b; Bowles 2000; Cleary et al. 1999; Crichton 1998; Nijman et al. 1997). This demonstrates a disparity between the use of choice and respect to facilitate functional interactions and behaviour. Setting limits is an attempt to control difficult behaviour; however, being inflexible only exacerbates problematic behaviour, thus reducing control. The goal is to provide opportunities for negotiating care. Psychosocial interventions provide a structure for this to occur more easily.
Lack of use of psychosocial interventions
For some time, the literature has expressed concern over the lack of routine use of psychosocial interventions within mental health services, including acute inpatient units (Gournay 1995; Sin & Scully 2008). One of the reasons for this situation has been the lack of skills and knowledge in the specific psychosocial interventions themselves (Baker 2000; Bowles 2000; Cleary et al. 2005; Gournay 1995; Gournay et al. 1998). It is unclear why such efficacious psychosocial interventions that directly address some of the reasons people are hospitalized are not more routinely provided. Mental health nurses are well placed to provide a number of these interventions because of the close involvement they have with patient care. This is further highlighted by the critical relationship between consumer outcomes and mental health nursing practice previously established in the literature (Rydon 2005). A lack of involvement in case presentations and review, ward rounds, and other multidisciplinary communication forums have also been noted in the literature. This is either due to lack of confidence or skills, perceived time pressures, or lack of perceived relevance. These are all vital for the implementation and continuation of psychosocial interventions (Bowles 2000; Cleary et al. 2005; Gournay et al. 1998).
For the purposes of this discussion, psychosocial interventions refer to the following:
- • Engagement & management of therapeutic alliance
- • Biopsychosocial assessment
- • Cognitive behaviour therapy
- • Dialectical behaviour therapy
- • Psychoeducation and relapse prevention
- • Stress management and problem solving
- • Medication adherence strategies
- • Motivational interviewing
(Baker 2000; Baker et al. 2005; Drury 1996a; Gamble & Brennan 2000; Gournay 1995; Happell et al. 2002; Kemp et al. 1998; Munro et al. 2005; Rydon 2005). It is a systematic return to the routine use of psychosocial interventions that I believe addresses many of the problems with mental health nursing practice identified in the literature.
ESTABLISHING ROUTINE PSYCHOSOCIAL INTERVENTIONS
In view of the criticisms of mental health nursing practice, mental health nurses require an approach to practice that can deal with the acute and chaotic nature of inpatient environments and provide treatments that work. The routine use of psychosocial interventions offers a practical solution to this problem. A range of very practical therapeutic interventions outlined earlier form the basis of this approach. For example, activity scheduling is a recognized cognitive behavioural strategy used for the management of depression.
The use of this strategy in acute inpatient units has demonstrated improvements in the levels of pleasure and satisfaction, with overall benefits for recovery from depression (Iqbal & Bassett 2008).
There are even treatments with emerging efficacies to deal with co-existing substance use problems, such as motivational interviewing (Baker et al. 2005).
While there is emerging evidence for psychosocial interventions, the degree of evidence available needs to be considered carefully. Many attempts have been made to empirically test the effectiveness of many of the psychosocial interventions. The level of evidence we call upon is significant in examining this concept (Mace & Moorey 2001; Parry et al. 2005).
There are five levels of evidence, ranging from expert opinion to randomized controlled trials. Randomized controlled trials are notoriously difficult to apply to psychosocial interventions. Because there are so many variables that can affect the outcome, it is difficult to determine whether the intervention tested was responsible. It is often unclear how treatments evaluated in experimental conditions will translate into the muddy world of clinical practice, including acute inpatient environments (Mace & Moorey 2001). However, lower levels of evidence, including professional consensus, would argue that CBT strategies should be part of treatment in an acute inpatient setting. In other words, with the available evidence, it makes sense and is worth providing. Arguably, treatments that are evaluated within clinical practice provide the most useful evidence. With all levels of evidence considered, we can appropriately refer to these psychosocial interventions as evidence based (Mace & Moorey, 2001; Parry et al. 2005).
This therefore presents another argument for mental health nurses to be involved in the routine provision of psychosocial interventions. We have sufficient insight into what is reasonably expected to work and can therefore embark on this process of routine provision. We need to keep adding to this evidence base by demonstrating that these interventions provided by mental health nurses in acute inpatient units can be clinically beneficial.
A number of benefits attributable to the use of psychosocial interventions are identified throughout the literature. These benefits can be summed up as follows:
- • Improved understanding of disorder
- • Reframing troubling thoughts and cognitions
- • Identifying potential causes/triggers
- • Building motivation
- • Enhancing coping strategies and responsibility
- • Enhanced self-management skills
- • Symptom relief and control
- • Enhanced problem-solving skills
- • Enhanced treatment adherence
- • Reduced recovery time
- • Changing patterns of maladaptive behaviour
(Baker 2000; Baker et al. 2005; Chadwick et al. 1999; Drury et al. 1996a,b; Fowler et al. 2000; Kemp et al. 1998; Lewis et al. 2002; Munro et al. 2005; Startup et al. 2004).
One of the main benefits of employing routine psychosocial interventions is the engagement and management of the therapeutic relationship required to provide them effectively. In other words, high levels of patient interaction and time spent with clients. Arguably, proactive time reduces the time responding to crises or incidences (Baker 2000). A consumer evaluation carried out in the UK highlights the importance placed on time spent with nursing staff (Brimblecombe et al. 2007). One of the other advantages is that psychosocial interventions are collaborative and skills based, therefore, encouraging a greater sense of responsibility to be taken by the patient. A patient who approaches a nurse with a problem in the corridor is an opportunity to engage the patient in teaching and reinforcement of problem-solving skills, rather than a solution being nominated to solve the problem on the patient's behalf. When increased ownership of the problem occurs, real intrinsic motivation to change can take place. There are also other benefits for mental health nurses in terms of professional credibility and job satisfaction.
Despite theses benefits, there are a number of reports in the literature that discuss the difficulties of mental health nurses implementing structured or planned therapeutic interventions. The reasons for this include time pressures, conflicting demands, role confusion, and lack of skills (Baker 2000; Cleary 2004; Cleary et al. 1999; Happell et al. 2002).
Therefore, we have to question our practice and decide whether these factors should prevent us from being involved in providing psychosocial interventions within acute inpatient units. There is a real opportunity to provide patients who have a mental disorder with those treatments and interventions that give them the best chance of bringing about symptom relief or even enduring recovery. So how do we balance the two?
Cleary (2003) highlighted the tension between paternalistic approaches and human rights within mental health nursing practice. There is a need to strike a balance between managing both the safety of clients and promoting independence and autonomy through a skills-based therapeutic approach (Bertram & Stickley 2005; Cleary 2003).
Apart from a lack of time or a lack of skills, the reluctance or inability to utilize such interventions may be linked to a perception that providing these interventions requires engagement in a deep form of ‘psychotherapy’. The use of psychosocial interventions on a routine basis includes both the structured approach, either from group or individual session, but also the incidental interactions where these interventions can inform and provide the basis of the interaction. This is where mental health nurse practice within acute inpatient units can be consolidated, if not excelled.
Implementation and sustainability
Having made the case for the routine use of psychosocial interventions by mental health nurses, the reality of the acute inpatient unit environment being chaotic and volatile, as well as one being dominated by a custodial culture, cannot be ignored. Therefore, a system that seeks to stabilize and counter the chaotic, volatile, and custodial nature of acute inpatient units is required in order to successfully sustain the implementation of psychosocial interventions.
Mistral et al. (2002) adapted therapeutic community principles to address problems with ward culture and chaotic environment. This arguably has the potential to successfully address some of the key barriers to providing psychosocial interventions within acute inpatient units. Nurses were seen as custodians struggling in their attempt to manage patients within this unit. The nurses felt that on one hand they were excluded from providing structured therapeutic interventions, and on the other, lacked the skills and/or were too busy when the opportunity to be involved was offered. This runs parallel to many of the problems with mental health nurse practice discussed earlier. As a result, Mistral et al. (2002) described a series of changes that were designed to address these problems.
It was noted that some staff addressed patients in an abrupt manner when attempting to seek information. Staff–patient communication was addressed through regular community meetings to de-emphasize the authority of nurses. Information about the unit routine and activities were provided as a way of patients taking more responsibility. Opportunities for both patients and staff to discuss any concerns were also part of these meetings.
The process involved regularly clarifying therapeutic aims and rules within the unit, as well as outlining unacceptable behaviour. Patients were seen as having an important role in ensuring unacceptable behaviour was addressed through a kind of peer pressure dynamic.
While there was no specific reference to educating staff in the provision of any specific therapeutic intervention, apart from the requirement to interact in a more meaningful way, these changes brought about significant benefits. These included improved communication and team cohesiveness, better relationships with management, more clarity and structure within the unit's operation, increased morale and job satisfaction, and reduced rates of seclusion and sick leave (Mistral et al. 2002).
Examples of psychosocial interventions within acute inpatient units
McGann and Bowers (2005) rolled out training in psychosocial interventions across seven acute inpatient mental health units in the UK. Training was offered to all mental health nurses in psychological interventions for psychosis, the stress vulnerability model, engagement and assessment processes, coping strategies, medication compliance, and working with families and carers. Additional training in motivational interviewing and working with voices and thoughts was provided to more skilled staff. Clinical supervision was provided as part of the training and ongoing implementation. As a result, two of the units were able to implement and continue to provide the interventions. The reasons for this success included strong support and participation from managers and stability of staffing.
Bowers et al. (2005b) developed a package for psychosocial interventions developed as a means of reducing absconding rates from 15 acute inpatient units across the UK. Some of the units were locked for some of the time. The package included clarifying rules, signing in and out, identifying higher-risk patients, careful breaking of bad news in terms of the language and communication style, post-incident debriefing, and multidisciplinary team reviews.
This study was able to demonstrate an absconding rate reduction of 25.5%. The value of the nurse–patient interaction was identified. The way nurses spoke to patients also had a significant bearing on patient behaviour and the risk of absconding.
Dedicated inpatient Dialectical behaviour therapy programmes have demonstrated reductions in self-harming behaviours among people with borderline personality disorder (Barley et al. 1993). Acceptance and validation were core principles of this programme and are arguably transferable to any acute inpatient unit. Providing an accepting and validating environment is a crucial component of mental health nursing practice, but is not always provided on a consistent basis (Bendit 2006).
It would seem that there is a mutual responsibility between staff and employers to ensure that psychosocial interventions are offered. In order to rise to this challenge, we require mental health nurses who are well motivated, well informed, and sufficiently trained and skilled.
It makes a lot of sense that acute inpatient units provide treatments that work and that mental health nurses be at the forefront of this provision. Staff training and professional development need to be systematized and well coordinated by identified experts. There is also a need for inpatient nurses to value interdisciplinary team approaches to care, such as ward rounds and case review meetings. It is vital that the unique perspectives and insights that mental health nurses can offer these forums are accessed in order to effectively plan and review treatment. Mental health nursing needs to make a cultural shift in order for practice to accommodate the routine use of these interventions. It will take more than individual nurses acquiring training to prepare themselves in the skills and knowledge that these interventions require. Training programmes, such as that described by McGann and Bowers (2005) need to be systematically rolled out across services to expose mental health nurses as a group to practice in this way.
However, it is a catch-22 situation, stable staffing, supportive management, and motivated staff with good morale are all necessary factors in providing successful psychosocial interventions on a routine basis (McGann & Bowers 2005). Ironically, job satisfaction is potentially enhanced through involvement in the provision of psychosocial interventions, leading to more stable staffing and improved morale.
Mental health nurses can feel powerless to break this cycle of reactive practice. It is acknowledged that acute inpatient units are busy, chaotic, and at times stressful places. This in itself is further argument for structured and planned approaches to practice.
It also takes a lot of energy to remain focused and committed to therapeutic programmes. However, Mistral et al. (2002) have demonstrated quite convincingly that no matter how busy chaotic or stressful a unit is significant improvements can be made.
As a result, psychosocial intervention programmes can succeed (McGann & Bowers, 2005). There is also a need to view these programmes as part of core business and not just another project that has a limited life span, only to see the return to former practices.
There is also no doubt that clinical supervision, along with broader professional development activities, play a key role in not only the overall practice of mental health nurses, but also the implementation of such structured programmes. Clinical supervision would need to be a key element in any comprehensive psychosocial intervention training. We are well aware of the benefits that clinical supervision can provide in improving job satisfaction and reducing burnout (Hancox et al. 2004; White & Roche 2006).
Another purpose for clinical supervision is to support the use of structure interventions, such as psychosocial interventions.
The importance of receiving clinical supervision when undertaking training in psychosocial interventions was well demonstrated by Bradshaw and Butterworth (2007). There is a mutual obligation between staff, managers, and clinical leaders to support sustainable clinical supervision arrangements. There is also a need for mental health nurses to embrace such supportive structures in a formalized way and make them a priority (Cleary & Freeman 2005).
The author would like to acknowledge the assistance of Professor Mike Hazelton (University of Newcastle, Newcastle, NSW, Australia) who provided invaluable input into the development of this paper.