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Clinical formulation for mental health nurses
Abstract
There are problems for mental health nurses in using psychiatric diagnoses as outcomes of their nursing assessments and nursing diagnoses present similar issues. However, there is a need in practice to link the assessment to nursing interventions in a meaningful way. This paper proposes that the clinical formulation can be regarded as central to providing this cohesion. The formulation does not merely organize the assessment findings but is also an interpretation or explanation, made in consultation with the client, of what meaning can be attributed to the issues explored in the assessment process. Because this interpretation is dependent on both the client's and the nurse's explanatory frameworks, there are multiple ways of developing the formulation. It is also an evolving and dynamic statement of understanding. A case example is provided in the paper to illustrate how the same case can be interpreted in different ways and the implications this has for the nursing interventions provided.
... [5] Some authors have tried to construct the theoretical framework of psychiatric nursing based on theories used in the mental health field, while others have identified nursing models or theories as being at the base of the theoretical framework for psychiatric nursing. [1][2][3][6][7][8][9][10][11][12][13][14] While constructing the theoretical framework for psychiatric nursing, each author attempted to explain why she or he chose these theories, and also tried to identify the relationship of each theory to nursing practices. [5] Authors associated the theories that they identified while constructing a theoretical framework of psychiatric nursing with psychiatric nursing practices as explained below. ...
... [9] Crowe et al. (2008) state that according to psychoanalytic theory, difficulties experienced by an adult result from his or her childhood, and nurses can help the individual learn new ways to solve problems by helping him or her to realize that coping mechanisms that served a purpose during childhood are ineffective in adulthood. [11] Similarly, based on Freud's psychosexual development theory, Halter (2013) states that childhood experiences have a profound effect on an individual's personality formation, and a nurse can research and identify the main causes of a patient's suffering using this information. [12] Halter (2013) also states that Erikson's developmental model is a fundamental element of patient evaluation, and a developmental framework helps nurses recognize which initiatives are the most effective. ...
... Based on this information, Shives (2008) states that nurses should focus on the changes in the development of individuals, non-adaptive behaviors, and interpersonal relations resulted with stress or anxiety. [9] Similarly, Crowe et al. (2008) state that nursing initiatives based on the interpersonal approach are performed to determine interpersonal patterns and how these patterns affect an individual. [11] They also report that nurses study an individual's needs in the relationship with his or her partner, his or her expectations for the relationship, his or her feelings, and how the individual's behaviors are perceived by his or her partner in their practices. ...
The use of theory in the mental health field can be traced back before
the 19th century. Later, with the detection of biological causes for the
formation of mental health problems, psychosocial theories and biological approaches began to be used together. Accordingly, some authors
tried to define the theoretical framework of psychiatric nursing, and it
has been said that the biological and psychosocial theories used in the
mental health field can also be used in the field of psychiatric nursing.
This article discusses how psychiatric nurses can use the theories that
constitute the framework of psychiatric nursing, and it explores this concept through the perspectives of the theories’ authors.
... These frameworks also explain the patients' main problems and these problems' causes, as well as any triggering, continuing, or protecting factors that provide a basis for these problems. [13] With these tools, nurses can knowledgeably approach individuals who display maladaptive behaviors and formulate an effective nursing care plan. Nurse initiatives and nursing care practiced in the light of a theoretical framework impart meaning and lead to efficacy because a theoretical framework sets proper boundaries for nursing initiatives. ...
... An approach to care that relates to a theoretical framework also contributes to the development of psychotherapeutic roles and responsibilities in the clinical practice of nursing. [12,13] ...
... As seen in Table 1, some authors have tried to formulate frameworks based on theories that are accepted as major tenets of psychiatric nursing practice; others have tried to formulate frameworks based on theories that are commonly used in psychiatric nursing practice; and others have tried to form them based on theories that are predominant in psychiatric nursing practice. [3,10,[12][13][14][15][16][17][18][19][20][21] Most frameworks defined by different authors include many theories which are somewhat similar to, but also somewhat different than each other. ...
Unless nursing practice is based on a sound theoretical foundation, it is
not possible to consider it as a profession. Therefore, taking a theoretical
approach is crucial for psychiatric nursing, as well as in other areas of the
nursing profession. Ideally, nursing should be undergirded by a theoretical framework that provides direction and guides its applications. These
guiding frameworks consist of various theoretical approaches that can
explain and define the problems of patients. When nursing interventions
are performed in the light of such theoretical frameworks, nursing care
can gain a more scientific basis. Some authors have defined theoretical
frameworks by considering the most effective ideas applicable to psychiatric nursing practices; some have formed theoretical frameworks by
considering the most widely used theories in psychiatric nursing practice; and others have generated theoretical frameworks using major
theories derived from psychiatric nursing practices. In this article, in light
of the existing literature, we discuss the necessity of a theoretical framework for the profession, theoretical frameworks that have been formulated for psychiatric nursing, and the application of theories that exists
within the framework of psychiatric nursing practices.
... Thus, organizational and political drivers rather than professional expectations drive the practice of MHN's developing and providing a provisional diagnosis to consumers. MHNs formulate a provisional diagnosis following assessment because it assists with the development of a nursing treatment plan (Crowe et al. 2008;Sands 2009). The formulation of a provisional diagnosis relies on the CDM skills possessed by the MHN. ...
... The articles from USA, Canada, Finland, and the Netherlands focused on CDM in aggressive behaviours resulting in the implementation of seclusion practices (Laiho et al. 2013;Mann-Poll et al. 2011;Moylan 2015;Riahi et al. 2016). The remaining articles published in New Zealand and Hong Kong focused on diagnostic practice in mental health nursing (Crowe et al. 2008;Lee et al. 2006). Stage 3: Study selection adopts similar methods to systematic review from the outset adopts greater flexibility with inclusion and exclusion criteria, as familiarity with data progresses search terms may be redefined (See Table 2 for inclusion and exclusion criteria) Abstracts of the returned results were read and studies were included and excluded based on the following: ...
... Six of the articles were literature reviews, and characteristics and concepts surrounding diagnostic practice in mental health nursing were identified in two of the articles (Crowe et al. 2008;Lee et al. 2006). Factors influencing CDM were explored in four articles (Crook 2001;Laiho et al. 2013;Moylan 2015;Riahi et al. 2016). ...
Medical diagnosis has traditionally been the role of medical officers. However, mental health nurses working in crisis/emergency settings within Australia are expected to provide a provisional diagnosis postassessment of a consumer. There is limited literature and understanding how mental health nurses develop a provisional diagnosis. In this scoping review, we aimed to first identify and describe the clinical decision‐making processes used by mental health nurses across a variety of clinical settings. Second, we sought to explore the factors influencing mental health nurse's diagnostic practice in a variety of settings. Literature was searched using CINAHL (EBSCOhost), PubMed, and ProQuest. Peer‐reviewed literature published between 2007 and 2017 was used for this scoping review. Two major themes were identified: clinical decision making (CDM) in mental health nursing and diagnostic practice in nursing. A combination of clinician, environmental, and patient factors were found to have influenced CDM. Furthermore, mental health nurses rely heavily on tacit knowledge when making clinical decisions. Little is known about the use of diagnostic practice in mental health nursing in Australia; however, the limited literature revealed an overlap between the factors which influence CDM and diagnostic practice, respectively. Further research is needed into the use of diagnostic practice in mental health nursing to develop frameworks to assist with CDM pertaining to application of provisional diagnosis by mental health nurses working in assessment environments.
... Changes in health-care provision to move towards more inclusive approaches that meet the needs of service users experiencing mental health problems have widened thinking on supportive treatment initiatives [Crowe et al. 2008, Department of Health (DH) 2009]. This push for inclusivity has forced organizations and practitioners to re-examine their practice methods and delivery styles in an attempt to move away from medication prescriptions and embrace psychological therapies. ...
... The Mental Health Foundation (2006) emphasize annually in the UK that one in four people's lives are disrupted by mental health issues, and the National Health Service (NHS) mental health criteria on risk assessment (DH 2007) means CF could provide a comprehensive review of physical, psychological and social needs. According to Crowe et al. (2008), purely using psychiatric diagnosis to guide treatments limits individualized care, and using a CF approach, irrespective of diagnostic classification, offers flexibility by linking assessment and interventions. Boschen & Oei (2008) describe CF as a map of issues explaining causal and maintaining factors, claiming it strengthens therapeutic alliance beyond those of diagnosis-based treatments. ...
... Hence, further research on practitioner feedback on the validity of their developed formulation would be useful in linking training and development needs. Crowe et al. (2008) suggest an advantage of CF is its ability to create understanding of service user needs regardless of their diagnostic classification. Thus an emphasis on the link between training provision, training outcomes and treatment plans is needed so practitioners understand the frameworks for conceptualizing mental distress whilst also being able to recognize the expertise of the service user in CF development. ...
Accessible summary • Explain the use of case formulation as a way of involving people experiencing mental health issues in their treatment options. • Case formulation is a framework that informs a choice of psychological treatments and links assessment and treatment phases to guide practitioners and individuals on treatment options. • This paper investigates its value and discusses training and supervision of professionals undertaking case formulation. • It includes information on how individuals with mental health issues are fully included in the process.
... Changes in health-care provision to move towards more inclusive approaches that meet the needs of service users experiencing mental health problems have widened thinking on supportive treatment initiatives [Crowe et al. 2008, Department of Health (DH) 2009]. This push for inclusivity has forced organizations and practitioners to re-examine their practice methods and delivery styles in an attempt to move away from medication prescriptions and embrace psychological therapies. ...
... The Mental Health Foundation (2006) emphasize annually in the UK that one in four people's lives are disrupted by mental health issues, and the National Health Service (NHS) mental health criteria on risk assessment (DH 2007) means CF could provide a comprehensive review of physical, psychological and social needs. According to Crowe et al. (2008), purely using psychiatric diagnosis to guide treatments limits individualized care, and using a CF approach, irrespective of diagnostic classification, offers flexibility by linking assessment and interventions. Boschen & Oei (2008) describe CF as a map of issues explaining causal and maintaining factors, claiming it strengthens therapeutic alliance beyond those of diagnosis-based treatments. ...
... Hence, further research on practitioner feedback on the validity of their developed formulation would be useful in linking training and development needs. Crowe et al. (2008) suggest an advantage of CF is its ability to create understanding of service user needs regardless of their diagnostic classification. Thus an emphasis on the link between training provision, training outcomes and treatment plans is needed so practitioners understand the frameworks for conceptualizing mental distress whilst also being able to recognize the expertise of the service user in CF development. ...
Accessible summary
Explain the use of case formulation as a way of involving people experiencing mental health issues in their treatment options.
Case formulation is a framework that informs a choice of psychological treatments and links assessment and treatment phases to guide practitioners and individuals on treatment options.
This paper investigates its value and discusses training and supervision of professionals undertaking case formulation.
It includes information on how individuals with mental health issues are fully included in the process.
The findings conclude that case formulation is worthwhile and suggests improved training to improve individual outcomes.
Abstract
Changes in mental health provision have led to practitioners and service providers reviewing how they incorporate service users in assessment processes and treatment decisions. Case formulation ( CF ) is a framework that informs a choice of psychological treatments providing a bridge between assessment and treatment phases to guide treatment options. However, CF is not routinely practised in mental health; hence this paper reviews CF literature to establish its efficacy for service users experiencing mental health issues. The purpose of this study is to assess the efficacy, reliability and validity of CF and its process and function in providing treatment for service users experiencing mental health issues and to explore practitioner training requirements. A systematic search of E nglish language publications on CF and treatment frameworks from 1999–2011 was conducted searching electronic databases. Additionally, two seminal pieces of CF work were included. The findings demonstrate evidence of CF 's efficacy and suggest practitioner training programmes to increase professional expertise and enhance service user outcomes. However, limited evidence exists and further research is required to address efficacy and training implications of CF .
... Formulation is fluid and dynamic and might best be considered a process rather than a product. Its quality often depends on the quality of the assessment and cultivation of a positive therapeutic relationship (Crowe et al 2008) founded on empathy, respect and attention to subjective experience (Gallop and Reynolds 2004). The formulation is developed from the summation and integration of knowledge acquired through assessment and interpreted according to an explanatory framework to elicit meanings. ...
... A shared understanding is developed through identifying links between experiences and the situational, psychological and social processes maintaining distress; placing behaviours and feelings in the context of why ways of coping have emerged and persisted to discuss their effects (Crowe et al 2008). Drawing on identified strengths and needs allows for collaborative selection of appropriate intervention(s) (Macneil et al 2012), which can be used to test hypotheses contained in the formulation (Kuyken 2006), for example, whether incrementally increasing activity affects thoughts about self and emotional state when depressed. ...
... structure and direct further research. Formative benefits include a broader knowledge base rather than a solely neurobiological understanding of mental health (Crowe et al., 2008), increased creativity (Brunero and Stein-Parbury, 2008) and a lasting influence on professional confidence (Arvidsson et al., 2008). Normative benefits have been found to include increased empathy (Brunero and Stein-Parbury, 2008), autonomy and improved cooperation between staff and patients (Severinsson and Hallberg, 1996). ...
... Formulationbased Milne et al. (2011) Supervision should be closely aligned in theory Buus et al. (2011) Successful supervision involves gaining a new perspective on a problem Summers (2006) Psychiatric staff perceived benefit of supervision as an attempt to understand Crowe et al. (2008) Help to broaden understanding and consider how therapeutic relationship can be helpful in care Berry et al. (2009) Formulations with the team helped change staff perspectives of patients with psychosis and improved care Modelling Kavanagh et al. (2002) Milne et al. (2011 Supervisor modelling clinical skills Feedback Kavanagh et al. (2002) Dodenhoff (1981 Reward and feedback in supervision has an impact on clinical practise Milne et al. (2011) Corrective feedback helpful for impact on practise Hyrkäs and Appelqvist-Schmidlechner (2003) Supervisees need to reach a consensus at the end of a session to maintain motivation Problem solving Kavanagh et al. (2002) Supervisee involvement Preparation Aston and Molassiotis (2003) Preparation by supervisor and supervisee important for successful implementation (Kavanagh et al., 2002) Negotiating the agenda of sessions improves effectiveness Sloan (1999) Recommend supervisees set agenda and responsible for documentation ...
Purpose
– Multidisciplinary team (MDT) clinical supervision is being used in many mental health services but at present has not received adequate attention by researchers in order to generate evidence-based approaches. The purpose of this paper is to explore the utility and staff perspectives of an MDT model of clinical supervision in the form of a “Clinical Discussion Group” (CDG) on an acute inpatient mental health ward within the context of the current literature on the components of effective supervision in order to make recommendations for practice.
Design/methodology/approach
– In total, 12 members of staff working on the ward were interviewed to gather their perspective on attendance, helpful aspects, outcomes, unhelpful aspects, and changes. Interview transcripts were analysed using thematic analysis.
Findings
– In total, 11 themes were identified, three within “The Group and how it operates” (attendance, discussion topics and facilitation), five within “Impact and Usefulness” (valued by staff, understanding a case, emotional benefit, learning and working together as a team) and three within “Changes to the Group” (organisation, discussion topic and group outcomes).
Originality/value
– This paper explores the benefits and challenges of a CDG from the perspective of the staff who attend. It presents some recommendations for good practice which should be of use to managers and supervisors who wish to use team supervision to improve patient outcomes and also makes suggestions for future research in this field.
... Strategies that promote selfacceptance, interactions with others and connection with nature, could also be utilized by nurses to promote recovery and healing. Developing clinical formulations with the patient (Crowe et al., 2008) to examine the role of acceptance and connection in their experience of health conditions provides a starting point. ...
There is increasing clinical interest in the use of psilocybin. There is emerging evidence of the efficacy of psilocybin for the treatment of a range of clinical conditions. Mental health nurses have a unique set of skills for caring for people who are hallucinating. To expand these skills to meet the developing clinical interest in the therapeutic use of psilocybin, it is helpful to understand the experience from the perspective of the person being treated with psilocybin. A qualitative meta-synthesis was conducted to examine how those with psilocybin described their experiences to identify whether its effects are similar across different health conditions. Ten studies were included in the review. The health conditions studied were cancer, depression, HIV, substance use disorder, smoking cessation and trauma. The synthesis of findings identified three themes that were common across the studies despite the health condition: acceptance, connection and transformation. The review provides helpful insights into how people experience psilocybin and its effects on their health condition.
... Recovery-based services need to be led by those with lived experience with clinicians providing support to facilitate connectedness, hope, optimism, identity, meaning and purpose, and empowerment. Services would no longer be structured around diagnosis but rather the clinician and the person in mental distress and their family would work together to develop formulations based on predisposing, precipitating, perpetuating, and protective factors (Crowe et al. 2008). This 4 P model examines the events and patterns in the person's life that contribute to their current distress. ...
This perspective paper aims to present a personal viewpoint on the impact of psychiatric discourse on the principles of recovery in mental health care. Mental health services espouse these principles, yet psychiatric discourse remains the dominant model. A critical analysis will examine how psychiatry maintains this dominance. The aim is to examine how psychiatric discourse constructs both the nature of mental distress and its treatment, and how it maintains its power as the dominant authority and its relationship to recovery principles. The paper concludes that psychiatric discourse is the antithesis of recovery principles and that its authority is perpetuated through co‐opting a medical explanatory model, claiming expertise in the ability to predict social risk, and maintaining a tightly controlled echo chamber. A way forward involves the dismantling of the hierarchical service delivery model based on psychiatric discourse and replacing it with a more horizontal service delivery model in which the lived experience of mental distress is central. Regular audit of services needs to prioritize recovery principles. The implications for mental health nursing are considered.
... The key to this is that mental health nurses need to provide the opportunity to access to a range of treatments, including medications, that will promote recovery. Mental health nurses can engage with people seeking treatment by co-operatively formulating the person's experiences in terms of predisposing, precipitating, perpetuating and protective factors (Crowe et al., 2008). This enables a shift from constructing those experiences as evidence of biochemical deficit and reframing them in terms of stress-vulnerability a treatment approach to depression more in-line with what the participants in this review wanted. ...
Accessible Summary
What is known on the subject?
Rates of antidepressant prescribing have been increasing.
Antidepressants are not effective for many people.
What the paper adds to existing knowledge?
Participants described how in order to receive help they had to engage with a medical pathway in which their experiences were constructed as arising from a biochemical deficit.
Antidepressant prescribing was identified as being the only option available and was associated with stigma.
What are the implications for practice?
Mental health nurses have a role to play in providing treatment options for those experiencing depression.
Mental health nurses need to provide evidence‐based information about antidepressants support those experiencing depression to make informed choices.
Abstract
Introduction
There are increased prescribing rates of antidepressants associated with an increase in the diagnosis of depression. However, antidepressants are not effective for many people. There is a gap in the existing literature for a synthesis of the experiences of those with lived experience of antidepressant use to better understand their use and impact given their ubiquitous use in mental health, primary care and other secondary and tertiary care settings. Mental health nurses play direct or indirect roles in both advocating for antidepressant use and monitoring adherence.
Aims
To identify how people prescribed antidepressants describe their experiences of the medication including its discontinuation?
Method
A meta‐synthesis of qualitative studies examining patients' experiences of antidepressant medication. Ovid MEDLINE, EMBASE, PsychINFO and Cochrane Library databases were searched in May 2021. One reviewer screened titles and abstracts. Two reviewers independently reviewed the retrieved papers for eligibility and data extraction. The data synthesis was conducted using thematic analysis. Two reviewers independently conducted quality appraisals.
Results
Twenty‐seven studies with a total of 2937 participants were identified for inclusion in this review. Four themes were identified across the studies: the only option available; stigma associated with ‘biochemical deficit’ not myself and the vicious cycle.
Implications for practice
Those seeking treatment for depression need to be provided with treatment options and evidence‐based information about anti‐depressants to provide them with the opportunity to make informed choices.
... It includes information about the procedures as well as thought processes of the therapist. It brings in the necessary aspects of flexibility and takes into account individual differences of each client (Crowe, Carlyle, and Farmar 2008) and bases therapist understanding specifically on what is being heard or seen (Roy-Choudry 2003). An important matter is to keep a balance between subjective impressions of the therapist and the clinical data. ...
Case formulation is a frequently used therapeutic tool that helps the therapist develop a better understanding of the client’s situation. Core concepts are strategies applied when sorting information about a client, assessing the importance of specific areas and taking appropriate actions in the therapeutic process. Although the area of case formulation has been explored in many other therapeutic approaches, there is a lack of deeper evidence on its use in the Gestalt approach. This article presents a qualitative research study that uses grounded theory for analyzing interviews with eleven Gestalt therapists. The resulting process model represents a theoretical conclusion about Gestalt therapists’ procedures in formulating clients’ cases. The research findings are discussed with the existing findings about the process of case formulation within Gestalt therapy and other therapeutic approaches. The outcome case formulation model can be helpful for practice, training, and supervision.
... We might want to fnd out whether this is the frst time she has had these symptoms, and whether she has stopped going to work or stopped studying because of them. As the nurse or other members of the team get to know Joanne and her family, they ought to draw on their evolving understanding and professional knowledge to develop a formulation of the problem, or an explanation/interpretation of what is going on-and, importantly, what might be done to help (Crowe, Carlyle & Farmar, 2008). ...
... All nurses ought to learn and practise communication skills, which are the foundational skills of psychotherapy. Furthermore, training in psychotherapy can be very helpful in developing formulations to explain and guide nursing practice (Crowe, Carlyle & Farmar 2008). ...
... Team formulation can increase staff knowledge; develop shared care; increase multidisciplinary working and improve dissemination of information (Craven-Staines et al., 2010). Team formulation can inform selection and planning of psychologically informed interventions; guide systemic changes to care (Taylor and Sambrook, 2012;Moore and Drennan, 2013); and provide meaning and direction to nursing care (Crowe et al., 2008). Thus, the goals of team formulation are: to improve staff knowledge and skills; and to improve care experiences and outcomes (Holmes, 2002;Kerr et al., 2007). ...
Purpose
Team psychological formulation is an organisational intervention aimed at developing a shared understanding of a person’s mental health difficulties. There is a lack of evidence regarding the therapeutic value of this approach for older people. The purpose of this paper is to explore how older people and their carers experience a cognitive-behavioural approach to team psychological formulation, within a mental health inpatient service in the UK.
Design/methodology/approach
A qualitative study using interpretative phenomenological analysis was undertaken. In total, 13 participants were interviewed: five older people/carer dyads, two lone older people and one lone carer.
Findings
Three overarching themes emerged: “Emotional impact of formulation” captured the mixed emotions that the process evoked in participants. “Making sense?” reflected the therapeutic value that participants experienced and what held them back from making gains in their recovery. “Disempowered people trapped in a biomedical world” illustrated the negative aspects of ward care, which hindered recovery.
Research limitations/implications
The findings provide insights into the therapeutic value of team psychological formulation and the difficulties in facilitating the process effectively. More consistency is required to ensure that team formulation is standardised. Further research into the outcomes of the approach for older people is recommended.
Practical implications
Recommendations are proposed for how team psychological formulation can be conducted effectively, using the mnemonic “SETUP”.
Originality/value
This study focussed on older people’s and their carers’ own perspectives regarding the team psychological formulation approach.
... There is limited research looking at the integration of clinical/reflective supervision and formulation within inpatient dementia care settings. For example, a specific formulation model has been developed for dementia care, The Newcastle Model ( James et al., 2006), but there is little evidence for the use of clinical formulation in nursing care (Crowe, Carlyle & Farmar, 2008;Smith & Grant, 2016), high- lighting a need for further research. It would be helpful to develop and evaluate their use in inpatient dementia set- tings. ...
Objectives: Existing literature demonstrates that nurses’ understanding of behaviours in dementia influences their responses to persons with dementia. However, there is limited research on the psychological processes involved in how nurses make sense of the behaviours and how these impact on responding, and a dearth of such literature from inpatient acute dementia settings. This study explored how inpatient psychiatric nurses make sense of and respond to behaviours in dementia.
Method: This study employed Interpretative Phenomenological Analysis (IPA), a qualitative method that explores in detail how participants make sense of their experiences. Eight inpatient psychiatric nurses were recruited from two inpatient services within a National Health Service Mental Health Trust. Semi-structured interviews were conducted to gain an in depth understanding of their experience. Transcripts of the interviews were then analysed using IPA.
Results: Four interrelated themes were identified: ‘Effort to sense make’, ‘Pressures of the organisation’, ‘Balancing personal and professional selves: The underlying emotional connection’; and ‘”Looking back on it…”’.
Conclusions: The study highlighted that sense making is a dynamic process, which occurs through a range of psychological processes and can change moment by moment dependent on the influences on the nurse. It demonstrated that nurses need to be supported to move flexibly through a range of emotional connections, which were found to underlie the negotiations made at work and influence sense making and responding. Nurses may benefit from space to reflect and formulate their understanding of clients, but further research is required to determine the effectiveness of this.
... The holistic assessment and the monitoring assessment are used as a platform for discussion of the young person and their situation. A clinical formulation framework (see Table 2) is applied throughout the team discussion (and preferred) as it examines what is happening for the person and not concerned with which diagnostic category or disorder the person meets (Crowe, Carlyle, & Farmer, 2008). These sessions create a space for nurses (where the young person's own words are paramount) to reflect on and share observations, consider the meaning this experience has for the individual, and understand their personal journey. ...
1 Topic
It is recognized that facilitating change in workplace culture is a significant challenge in healthcare service delivery. Practice development strategies and principles provide a framework for initiating and sustaining programs focused on enhancing patient‐centered care by concentrating on the therapeutic attributes of nursing. However, little literature exists on explicating “what worked” in practice development programs.
2 Purpose
This paper details the processes, people, resources, and relationships that enabled the successful implementation, and led to the sustainability, of a practice development program employed in an acute adolescent mental health unit in Sydney, Australia.
3 Sources used
Following an external review of the unit, a meeting of key stakeholders was convened and subsequently an advisory panel formed to address specific issues facing nursing staff. This process resulted in the development of an educational package and adoption of the tidal model as the framework for mental health nursing practice in the unit. Clinical reasoning sessions and journal article presentations were incorporated to consolidate and maintain the change in nursing care.
4 Conclusions
A planned, structured, and inclusive practice development programhas transformed the nursing culture and vastly improved the care provided to adolescents presenting in acute states of distress to this mental health unit.
... Formulation is more than a summary of descriptive information about the patient's presenting problem leading to a diagnosis. By itself, providing a diagnosis does not complete the process of evaluation [6]. Some authors argue that using only psychiatric diagnosis to guide intervention limits individualized care, while case formulation allows flexibility. ...
Aim of the study
Formulation is considered a key competence that should be taught during psychiatry training in residency. The scientific literature indicates shortcomings in teaching this clinical skill such as a lack of standardization and clear guidelines. The main objective of this research was to examine psychiatry residents’ perception regarding teaching of formulation in Canadian psychiatry residency programs.
Subject or material and methods
All Canadian psychiatry program directors in English programs were emailed a link for the study survey. The survey had a mix of closed and open-ended questions. With the exception of one Program Director, the survey link was distributed by all of the Program Directors. 116/661 (17.5%) of residents completed the survey.
Results
Overall, results of this survey indicated that residents did not feel very competent in their formulation skills, although they felt this was an important ability. Residents mostly learn it through individual supervision or through mentoring with a senior resident.
Discussion
Residents suggested a more structured approach in teaching formulation, as well as adding a small group format or workshops.
Conclusions
This research could provide guidance to educators in developing new curricula in the context of the upcoming transition to the competence-based framework by the Royal College of Physicians and Surgeons of Canada.
... No reference could be found in the literature about a psychotherapeutic intervention model in nursing aiming to help solve nursing diagnoses, which hinders the discussion on the nursing diagnoses that can incorporate the model. According to Crowe, Carlyle, and Farmar (2008), due to the centrality of medication prescribed (by a psychiatrist) as the treatment outcome of the diagnostic process the recourse to psychiatric diagnoses has limited utility to mental health nursing practice. However, mental health nurses seem to feel more comfortable to comply with this sort of diagnoses. ...
Aim: To estimate the content validity of a psychotherapeutic intervention model in nursing.
Background: Mental health nurses encounter great extrinsic difficulties when it comes to providing psychotherapeutic interventions due to the fact that they are not allowed to perform such practice in some countries. In this light, the pursuit of a psychotherapeutic intervention model in nursing seems germane to guide the professionals' psychotherapeutic practice, contributing hereof to increase mental health nurses' professional autonomy.
Design: Modified e-Delphi.
Methods: Data were collected from October 2015 to January 2016 by means of three rounds of online questionnaires. The initial questionnaire was structured into five sections: general structure of the model, patients' exclusion criteria, assessment framework, nursing diagnoses, and nursing psychotherapeutic interventions. From the 42 experts invited, at least twenty (20) participated in each round.
Results: The experts achieved consensus with regard to the conclusion that nursing psychotherapeutic interventions should always seek to address a nursing diagnosis. These defined furthermore that a psychotherapeutic intervention model in nursing should be exercised by means of 3 to 12 sessions using Nursing Interventions Classification (NIC) as a resource. Finally, experts deemed that the model should follow the principles of integrative psychotherapy, so that techniques from different schools of psychotherapy could therefore be used in conjunction to promote the resolution of a nursing diagnosis.
Conclusion: Achieving consensus about the structure of a psychotherapeutic intervention model in nursing is imperative to guide nurses in the provision of nursing psychotherapeutic interventions and to enable an effective evaluation of the health gains associated with its implementation.
... They might, for example, acknowledge that a particular diagnosis simply means that a person has a particular cluster of symptoms and acknowledge that this does not imply that the cause, treatment, or prognosis can be derived from the diagnosis. A well-crafted formulation (Crowe, Carlyle, & Farmar, 2008;Rainforth & Laurenson, 2014) arrived at through careful listening and judicious consideration of research and theory is what care and treatment ought to be based, not a psychiatric diagnosis. Nursing organisations ought to align themselves with other professional groups such as the British Psychological Society (2013) which, in a strongly worded position statement, called for a paradigm shift away from diagnosis and toward an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience. ...
... The Division of Clinical Psychology, within the governing body of the BPS (2011), considers formulation as a core skill for clinical psychologists in all areas of practice. In psychiatric nursing (Crowe, Carlyle & Farmer, 2008) formulations are regarded as central to organising assessment findings and developing, as well as interpreting, the meaning attributed to issues the client brings to the assessment process. ...
Problem formulations are often said to be essential to ethical therapeutic interventions by professionals working therapeutically in mental health. These formulations provide an explanation of the problem along with a road map of what needs to change to ameliorate the problem. The lack of focus on problems puts solution focused work at odds with most other mainstream therapies, and a lack of problem formulation is but one of the differences thrown up by working in a solution focused way. The author describes very briefly the history of problem formulations then describes how SF work addresses some of the features said to be common to these formulations. A diagram of a possible SF formulation is given. It is the author's conclusion that SF workers do a type of co-formulation with clients that meets many of the 'requirements' of a problem formulation process. There is much more work needed to determine whether or not SF therapists wish to engage in a type of formulating or whether we, as a group, adopt the stance that formulations are not established as necessary for ethical, effective therapeutic working.
... Individuals in recovery have told researchers what they needed were relationships that helped them make sense of themselves. In this light apprehending how stories weave into a narrative is a critical step in recovery since the experience helps individuals establish some meaning and control over their experiences [37] . ...
Since introduced by Peplau in the 1950's the psychotherapeutic relationship has been a defining element of psychiatric mental health (PMH) nursing practice. While the components of the therapeutic relationship have been detailed over the decades, PMH nurses appear to be faltering in particular aspects of the relationship process. Individuals hospitalized on inpatient psychiatric units have reported that nurses often failed to engage. Nursing leaders believe that the specialty has not articulated what PMH nurses do within the relationship that helps clients lead a more meaningful life. We suggest what remains ambiguous is not what nurses do within the relationship but the language to depict the mental processes involved in relationship building particularly in the engagement phase. Using the language of interpersonal neuroscience three key engagement processes are detailed, i.e., resonance, attunement and mentalizing. The healing elements of the relationship are explored particularly how attention to individuals' narratives of experiences supports their movement towards integration and coherence.
... It could be argued that mental health nurses have co-opted psychiatric discourse into their everyday practice and thus constructed a limited and dependent role for themselves and have failed to explore other possibilities for those that they nurse (Crowe, 2000b). Nurses need to be careful not to accept any new diagnoses without question and to look beyond the psychiatric diagnosis to a wider consideration of the person's needs that could be better articulated in a clinical formulation (Crowe, Carlyle, & Farmar, 2008). ...
... The holistic assessment and the monitoring assessment are used as a platform for discussion of the young person and their situation. A clinical formulation framework (see Table 2) is applied throughout the team discussion (and preferred) as it examines what is happening for the person and not concerned with which diagnostic category or disorder the person meets (Crowe, Carlyle, & Farmer, 2008). These sessions create a space for nurses (where the young person's own words are paramount) to reflect on and share observations, consider the meaning this experience has for the individual, and understand their personal journey. ...
Topic
It is recognized that facilitating change in workplace culture is a significant challenge in healthcare service delivery. Practice development strategies and principles provide a framework for initiating and sustaining programs focused on enhancing patient‐centered care by concentrating on the therapeutic attributes of nursing. However, little literature exists on explicating “what worked” in practice development programs.
Purpose
This paper details the processes, people, resources, and relationships that enabled the successful implementation, and led to the sustainability, of a practice development program employed in an acute adolescent mental health unit in S ydney, A ustralia.
Sources Used
Following an external review of the unit, a meeting of key stakeholders was convened and subsequently an advisory panel formed to address specific issues facing nursing staff. This process resulted in the development of an educational package and adoption of the tidal model as the framework for mental health nursing practice in the unit. Clinical reasoning sessions and journal article presentations were incorporated to consolidate and maintain the change in nursing care.
Conclusions
A planned, structured, and inclusive practice development program has transformed the nursing culture and vastly improved the care provided to adolescents presenting in acute states of distress to this mental health unit.
... Formulation can be used to explain difficulties to both the client and the team (e.g. Dunn and Parry, 1997;Crowe et al., 2008) with team formulation often used when the team feels stuck or when it appears that progress is not being made (Christofides et al., 2012). Although views on explicitly sharing a formulation in full with a client can differ on the basis of the therapeutic model being used (e.g. ...
Forensic case formulation, of increasing interest to practitioners and researchers raises many ethical, theoretical and practical issues for them.
Systemic, contextual and individual factors which need to be considered include the multitude of staff often involved with any one individual, the pressure to 'get it right' because of the range of risk implications that are associated with individuals within forensic mental health settings, and individual parameters, for example reluctance to be engaged with services. Copyright © 2013 John Wiley & Sons, Ltd.
... Other clinical professions have made less use of the concept. Apparently, 'there is no literature available on the use of clinical formulation in mental health nursing practice despite the opportunities it provides for developing more effective psychotherapeutic nursing interventions' (Crowe et al., 2008). This is of concern because mental health nurses are often key workers for mentally disordered offenders (Doyle and Dolan, 2002). ...
... Further, it is unclear whether any adverse effects of HT are confined to the period of receiving HT or remain after treatment. If HT does induce depression, then targeting patients' specific symptoms may be beneficial because this kind of clinical case formulation [7][8][9][10][11] of depression is especially relevant when a physical illness is coupled with a mental illness [12]. In addition, depression is often comorbid with anxiety, and that comorbidity predicts resistance to treatment [13][14][15], delayed recovery, poorer quality of life, and increased suicide risk [16,17], and has been reported in 10.2 % of PCa samples, with 6.2 % fulfilling the criteria for depression alone and 8.5 % for anxiety alone [18]. ...
Background:
To investigate the relationship between hormone therapy (HT) and incidence of anxiety and depression among prostate cancer patients (PCa).
Methods:
526 PCa patients completed a survey about their cancer status, treatment received, anxiety, and depression status. Total scores on anxiety and depression inventories, plus symptom profiles that discriminated between patients with current HT, past HT, and never having received HT, were compiled for analysis.
Results:
Patients who were currently receiving HT had significantly higher total anxiety and depression scores than patients who had previously received HT or who had never received HT. Analysis of the symptoms of anxiety and depression which distinguished between these groups of patients suggested that patients who had never received HT had significantly lower scores than current or past HT patients. Although several symptoms could be directly allocated to PCa and/or HT, symptom profiles were indicative of clinically significant anxiety and/or depression in patients who were currently receiving, or who had previously received, HT.
Conclusion:
Current HT may lead to symptoms of anxiety and/or depression which require clinical attention. These effects seem to decrease after completion of HT.
... A genogram is also used to gain an understanding of the important people in a person's life and the nature or quality of these relationships. The information gained is then developed into a clinical formulation as described by Crowe et al. (2008), which when used for bipolar disorder includes: ...
Accessible summary
Bipolar disorder is a severe and recurrent mental disorder that has a long‐term impact on the patient's ability to function.
Specialist supportive care is a manualized psychotherapy that provides support and psycho‐education for self‐management.
This study provided specialist supportive care as an addition to usual care from community mental health services.
It is not feasible to provide specialist supportive care to patients with bipolar disorder while they are in mood episode and receiving usual care.
Abstract
The aim of the study is (1) to assess the feasibility of delivering nurse‐led specialist supportive care as an adjunct to usual care in the clinical setting; (2) to examine the relationship between the delivery of specialist supportive care and improved self‐efficacy and functioning and reduced depressive symptoms. A randomized controlled trial of the clinical effectiveness of specialist supportive care as an adjunct to usual care was conducted in community mental health services at one site. Participants were randomized to either usual care or usual care and the adjunctive intervention. Self‐report measures of depression, general functioning and self‐efficacy were completed by participants in both groups at baseline and 9 months. The intervention was delivered parallel to usual treatment arrangements. While recruitment numbers were sufficient, a low rate of engagement meant we were unable to show significant differences in depressive symptoms or self‐efficacy between the usual care group and the specialist supportive care plus usual care group. This study demonstrated that it was difficult to engage patients with bipolar disorder in specialist supportive care when they were currently in a mood episode and under the care of community mental health services.
... Expert knowledge is partial and provisional with as yet no definitive proof to support one perspective over another (Morant 2006). This heterogeneity of paradigms potentially has significant expertise to offer consumers of mental health services (Crowe et al. 2008) and it has been suggested that different values, views and perspectives are a strength in a multidisciplinary team (Lankshear 2003, Williamson 2004 ). However, this strength is dependent upon recognition and respect for differences. ...
Accessible summary
Mental health nursing care is usually delivered in multidisciplinary teams within inpatient and outpatient settings. This team approach to care delivery is underpinned by an assumption of a common set of values and a common model of care delivery among disciplines.
Mental health nurses appear to endorse a range of explanatory conceptual models as important in respect to aetiology, treatment, and factors influencing improvement, the role of the mental health service and the role of nurses. This study found that although the participants used a psychodynamic framework for understanding the causes of mental distress they described the presenting problems and the nursing interventions in terms of supporting a medical model of care.
Mental health nursing care is subjugated by a medical model which constrains the possibilities for mental health nursing interventions. This then potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting.
Abstract
The aim of this study was to identify the conceptual models that underpin mental health nursing care in clinical settings. This study is a modification of a previous study which evaluated the influence of implicit models of mental disorder on processes of decision making within community‐based teams. Participants completed questionnaires in response to a scenario. A range of explanatory conceptual models were identified in respect to aetiology, treatment and recovery. In a forced choice the participants ranked a medical model of care above other models as underpinning care delivery. The content analysis found that the participants used a psychodynamic framework for understanding the causes of mental distress but described the nursing interventions in terms of supporting a medical model of care. Nursing care is dominated by a medical model which constrains mental health nursing. This potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting. A range of psychosocial approaches to mental health care delivery have been developed, but there seems to be problems with their implementation in practice. Further research is required to explore how broader therapeutic interventions can be implemented by nurses within multidisciplinary systems of mental health care delivery.
... The application of unitary explanations of mental illness it would seem are inadequate when answering complex questions regarding the human condition (Gallop & O'Brien, 2003). Crowe et al (2008) contend that contemporary mental health care is populated by co-existing multiple paradigms; biological, cognitive, interpersonal and psychodynamic. Acceptance of this heterogeneity can help mental health nurses to collaborate and work in partnership with the person experiencing mental distress. ...
Unitary explanations of mental illness symptoms appear to be inadequate when faced with everyday experiences of living with these conditions. In particular, the experience of voice hearing is not sufficiently accounted for by biomedical explanations. This paper revisits data collected from a sample of people who hear voices to perform a secondary analysis with the aim of examining the explanatory devices deployed by individuals in their accounts of voice hearing. Secondary analysis is the use of existing data, collected for a previous study, in order to explore a research question distinct from the original inquiry. In this study, we subjected these data to a thematic analysis. People who hear voices make use of standard psychiatric explanations about the experience in their accounts. However, the accounts paint a more complex picture and show that people also impute personal meaning to the experience. This in turn implicates both personal and social identity; that is, how the person is known to themselves and to others. We suggest that this knowledge can inform a more thoughtful engagement with the experiences of voice hearing by mental health nurses.
... Much has been written about the limitations of diagnoses in psychiatry, but perhaps the greatest of problems arise when their use presumes unfounded aetiological and prognostic certainty; when they don't illuminate the problem or provide for an effective solution. Various schools of psychotherapy, and more recently nursing (Crowe et al. 2008), have put increasing emphasis on formulating explanations for how problems develop, are maintained, and can be resolved. The measure of success is the degree to which the formulation fits with a person's values and beliefs and leads to positive resolution of problems. ...
This chapter aims to provide an understanding of advanced clinical assessment skills in mental health practice that considers the interface between physical and mental health, comorbidities, complexities and environmental and social factors. Advanced mental health assessment and decision-making require intuitive and analytic clinical reasoning, critical thinking, professional knowledge and shared decision-making. It also requires the integration of nursing knowledge, with knowledge from other fields (medicine, psychology, sociology, pharmacology). In addition, a comprehensive assessment needs to be underpinned by the principles of recovery, trauma-informed care and a strengths-based approach. Therefore, it stands to reason that these concepts will be incorporated in this chapter by focusing on the knowledge and skills required to build an account of why and how problems arise, developing collaborative formulation and goal settings, whilst managing the challenges and pitfalls of the essential part of the therapeutic process.KeywordsAdvanced mental health nursing assessmentPsychological formulationRecoveryTrauma-informed careStrengths-based approachDecision-makingCritical thinkingAwareness
Diagnosed sleep disorders and broadly defined ‘sleep problems’ are more prevalent in children with development delay (global developmental deficits, adaptive functioning deficits and intellectual disability) when compared to estimates from typically developing children. Given the complexity of this association, a person-focused approach to the study of sleep in children with developmental delay is warranted. There are, however, issues with this approach in clinical practice, as sleep parameters are largely understood within the context of a typically developing framework. This chapter considers some of the key comorbid factors that may explain the complex association between poor sleep and developmental delay and reflect on some of the practical implications around assessment of sleep in children with additional needs. Clinical aspects relating to biological and behavioural models of sleep, potential perpetuating and protective factors in the context of a clinical formulation and avenues and barriers to behavioural and medical sleep interventions are also discussed. Throughout this chapter, researchers and clinicians are encouraged to consider both individual and familial needs when working towards assessment and treatment objectives for sleep problems in at-risk groups.
Objective:
to analyze the management of mental health needs in primary care as perceived by Family Health Strategy professionals.
Method:
this was a qualitative descriptive exploratory study developed within the coverage area of five family health teams. The data were collected using observation, group interviews, individual semi-structured interviews, and focus groups. Content analysis was conducted using text analysis software and interpretation was based on the corresponding analytical structures.
Results:
numerous and challenging mental health demands occur in this setting, for which the teams identified care resources; however, they also indicated difficulties, especially related to the operationalization and integration of such resources.
Conclusion:
there is a need for a care network sensitive to mental health demands that are better coordinated and more effectively managed.
Objectives:
This paper proposes the use of the cognitive domain of Bloom's Taxonomy, an educational classification system, to guide the critical thinking required for the composition of the psychiatric formulation during the various stages of specialist training.
Conclusions:
Bloom's Taxonomy offers a hierarchical, structured approach to clinical reasoning. Use of this method can assist supervisors and trainees to understand better the concepts of and offer a developmental approach to critical reasoning. Application of the Taxonomy, using cognitive 'action words' (verbs) within each of the levels, can promote increasing sophistication in the construction of the psychiatric formulation. Examples of how the Taxonomy can be adapted to design educational resources are suggested in the article.
Objective:
To know how the nurse provides care in the first psychotic outbreak of patients, and to identify the Barbara Carper patterns of knowing used for this action.
Methods:
A qualitative study using a phenomenological approach was performed in four Psychosocial Care Centers and in a psychiatric ward of a university hospital. Data collection was carried out with ten nurses participating in semi-structured interviews using the following guiding question: "Tell me your experience in caring for a patient in their first psychotic outbreak".
Results:
Carper's fundamental ways of knowing (empirical, aesthetic, ethical and personal) were identified in the caring of the patient in their first psychotic outbreak.
Conclusion and Implications:
A fragmented practice is implied when patterns of knowledge are taken in isolation. This reflects on specific actions of nursing work, such as the nursing practice and its stages.
Objective:
to identify evidences from the literature on the application of nursing process in care developed by the nurse in mental health.
Method:
integrative literature review between 1990 and 2013, in the PubMed, Scopus, CINAHL and LILCACS bases. Descriptors: nursing processes, mental health, nursing care.
Results:
19 papers were identified. Limited and partial usage of the nursing process in care established by a therapeutic relationship that respects the patient’s individuality. We observe care proposals systematized for patients that present pathological aspects in the limits between the physical and psychical, which might be a response to the influence of the practice based on evidences.
Conclusion:
it was found an antagonistic movement between care based on the relationship and located in the standardization of diagnoses that respond to physical malaise. A lack of evidence was verified for the usage of the nursing process in mental health, and we point at the necessity for the creation of new possibilities for dialogue between relational and biological perspectives.
In this article, we contribute to understanding the interactional aspects of making clinical diagnosis in mental health care. We observe that therapists, during the “problem presentation” sequence in clinical encounters, often use a specific form of diagnostic formulations to elicit more diagnostically relevant information. By doing so, they often substitute one type of verb with another, following a diagnostic hypothesis. Specifically, in interviews that arrive at a diagnosis of neurosis, therapists formulate with behavioral verbal processes; in interviews that arrive at a diagnosis of psychosis, they do so with material ones. Such formulations often prove useful to define clinical diagnoses. They can, however, also be dangerous in that they may favor the therapist’s agenda over the patient’s. Our analysis helps therapists not only better understand the diagnostic process but also reflect upon their own use of diagnostic formulations and become aware of the clinical effects of their interactional performance.
There is little written about the use of psychological formulation by staff working in adult mental health, despite it being on the curriculum for nursing and psychiatry training in the UK. A psychological formulation training day was held, and changes in mental health staff knowledge, attitude, confidence, capability and potential for change in clinical practice using a cross-sectional questionnaire design were evaluated pre-and post-training. A ‘5Ps’ model of formulation was used as a basis to train staff in formulation. In total, 28 mental health staff including nurses, healthcare assistants, trainee clinical psychologists and occupational therapists attended the formulation training day. Findings revealed overall increases in knowledge, confidence, capability and intentions to use in practice for participants. Clinical implications and limitations in terms of ceiling effects for certain items and the small numbers are discussed.
This paper examines the mental health consultation-liaison nursing (MHCLN) role and links this to the interpersonal relations theory of nurse theorist Hildegard Peplau. The paper argues that, as mental health nursing care around the world is increasingly focused upon meaningful therapeutic engagement, the role of the MHCLN is important in helping to reduce distressing symptoms, reduce the stigma for seeking help for mental health problems and enhancing mental health literacy among generalist nurses. The paper presents a small case exemplar to demonstrate interpersonal relations theory as an engagement process, providing patients with methodologies which allow them to work through the internal dissonance that exists in relation to their adjustment to changes in life roles precipitated by physical illness. This dissonance can be seen in the emergence of anxiety, depression and abnormal/psychogenic illness behaviours. This paper concludes arguing for considerable effort being given to the nurse-patient relationship that allows for the patient having freedom to use strategies that may help resolve the dissonance that exists.
The aim of this study was to use a phenomenological methodology to examine mental health nurses' experiences of administering medications to patients who were non-adherent in an acute inpatient service.
There is a large body of literature focused on exploring the issue of non-adherence to prescribed medication, but there is very little examining this from mental health nurses' perspectives. Many of the medications prescribed for patients diagnosed with a psychiatric disorder have serious side effects and limited efficacy. Mental health nurses in acute inpatient environments are regularly confronted with the difficulties inherent in the conflicting roles associated with the need to maintain therapeutic relationships and the expectation that they ensure patients take their medications.
This is a qualitative study exploring mental health nurses' descriptions of managing medication adherence in an acute inpatient unit.
The interpretive phenomenological methodology of Van Manen (Researching Lived Experience: Human Science for an Action Sensitive Pedagogy, 1990) was used in this study to capture the experiences of a group of nurses. This research process involves a dynamic interplay between the following six research activities: (1) turning to the nature of the lived experience; (2) investigating the experience as we live it; (3) reflecting on essential themes; (4) a description of the phenomenon through the art of writing and rewriting; (5) maintaining a strong and oriented pedagogical relation to the phenomenon; and (6) balancing the research context by considering parts and whole.
Four themes emerged from the existential analysis that described the mental health nurses' experiences: doing the job for doctors (relationality); stopping and listening (temporality); stepping in (corporeality); and walking a fine line (spatiality).
It is proposed that models of therapeutic interventions offering alternative or conjunctive treatment to medications could be incorporated into acute inpatient care and provide an enhanced therapeutic model.
Nurses in many areas struggle to manage the tensions between a medical model and a nursing model of care. This study describes how one group of nurses manage these tensions and suggests a more patient-centred model of care.
This paper is a report of a study identifying psychosocial interventions relevant to routine care and exploring their content critically and analysing patterns in the use of these interventions.
People experiencing enduring and serious mental disorders value psychosocial engagement as a means of achieving recovery and rehabilitation. However, mental health nurses' use of person-centred and directive psychosocial engagement in routine care is unclear, with the potential arising for benevolence and paternalism.
A think aloud study was carried out with 37 mental health nurses responding to a simulated case depicting a person with an enduring mental health problem. Participants were recruited from community and acute hospital facilities across Ireland and responded to two tasks: identifying the nature of the person's problems and recommending what to do next. Transcripts were coded using judgement and intervention themes designed for the purpose. Patterns in the use of psychosocial intervention themes were described and further analysed by level of experience (highly experienced or not) and practice setting (acute/community setting).
A task-oriented psychosocial intervention labelled structured engagement was used extensively, followed by reassurance and encouragement based on pragmatic communication. A minority of nurses used dialogue, representing person-centred care. Highly experienced community mental health nurses were the most likely to talk in terms of intensive psychosocial engagement.
Relying on pragmatic problem-solving is problematic in terms of decision-making transparency and service user involvement. The use of informal knowledge in practice should be negotiated through more open discussion by nurses, including adoption of a consensus on the components of psychosocial care.
Being able to discern the presence of a central organizing linchpin in a given clinical case represents a highly advantageous state of affairs. One can, by virtue of this, proceed in a very efficient and economical, as opposed to piecemeal, fashion. Further, one can achieve this economy and efficiency without paying the price of superficiality, since one is getting to what might be termed "the heart of the matter" in the client's case. Finally, one has in a linchpin formulation a central blueprint that provides (a) a clear, constant goal for therapist and client; (b) a clarification for clients of both their power and of where and how they would best target their efforts; and (c) a vast heuristic suggestiveness as to how one might proceed therapeutically to bring about important change.
It has been suggested that the crucial elements in nursing situations are the nurse, the client, and what goes on between them. This paper examines what goes on between clients and nurses during interpersonal relationships, from the perspective of the clients. Data are presented from studies conducted in Canada and Scotland. It is shown that what clients want, or do not want, during relationships with their nurses, is similar on both sides of the Atlantic. The findings reported in this paper are relevant to transcultural nursing, ethical care, the growth in consumerism, and client advocacy. The findings suggest also that there is a need for nursing research to focus on clinical outcomes in order to establish whether clients' perceptions of helping relationships have any relevance to favourable health outcomes, and the evidence base for clinical nursing.
Case formulation has been recognized to be a useful conceptual and clinical tool in psychotherapy as diagnosis itself does not focus on the underlying causes of a patient's problems. Case formulation can fill the gap between diagnosis and treatment, with the potential to provide insights into the integrative, explanatory, prescriptive, predictive, and therapist aspects of a case. Despite the acknowledgment that case formulation is a basic, necessary, and key clinical skill, it is still largely undertaught and underlearned. Some of the issues faced in the development of a case formulation include that of immediacy versus comprehensiveness, complexity versus simplicity, observation versus organization, and the need for cultural sensitivity toward each individual patient.
The authors propose five aspects of case formulation beneficial to therapists and residents in training.
The authors argue that case formulation remains an important and indispensable integrative tool for therapists and residents in training who are involved in psychotherapeutic interventions.
Anxiety and mood disorders are prevalent in the Australian community and can be functionally disabling. Access to treatment for these disorders can be difficult, particularly in rural areas where there is limited availability of specialist mental health practitioners such as psychiatrists and clinical psychologists. One way to address this problem is to improve the skills of local mental health practitioners in recognizing and providing treatment for these disorders. This paper describes a program that aimed to enhance access to psychological treatment for depression and anxiety by improving the skills of rural mental health case managers through training and education and support by psychiatrists and clinical psychologists. Thirty-two case managers participated in the program which delivered 10 training modules using a cognitive behavioural therapy framework. Case managers consisted primarily of psychiatric nurses, with others having social work or psychology backgrounds. Participants were assessed pre- and post-training using quantitative and qualitative measures. The effect of the training was noted in several areas including attitudinal changes, improved knowledge of psychological therapies, and changes to stated practice. However, there was concern expressed by participants about their competence and confidence to translate skills learned into practice. While the results of such a program are promising, they highlight some of the complexities of delivering such programs in rural settings.
Limited research on the reliability of cognitive case formulation suggests cognitive therapists can agree about clients’ presenting problems but show poor agreement about the inferential aspects of formulation. There has been no research examining the quality of practitioners’ case formulations. This study assessed whether participants with different levels of experience could produce reliable cognitive formulations using a systematic cognitive therapy case formulation method: the J. Beck Case Conceptualization Diagram. As part of continuing education workshops on cognitive case formulation, 115 mental health practitioners were given the same case description and asked to provide case formulations. Inter-rater agreement and agreement with a “benchmark” formulation provided by J. Beck were measured. The results showed that participants were able to agree with each other and with the benchmark on most descriptive aspects of the formulation but rates of agreement decreased for aspects of the formulation requiring greater levels of theory-driven inference. Based on definitions and measurements of the quality of cognitive formulations derived in this study, the quality of formulations ranged from very poor to good, with only 44% rated as being at least good enough. Both reliability and quality of case formulations were associated with levels of clinical experience and accreditation status. Implications for training and supervision are discussed.
All psychiatrists should be able to construct a psychodynamic formulation of a case. A key advantage of formulation over diagnosis is that it can be used to predict how an individual might respond in certain situations and to various psychotherapies. This article looks in some depth at what psychiatric trainees need to be taught about psychodynamic formulation. We introduce formulation in terms of four levels, each level corresponding to a different degree of theoretical and clinical sophistication and therefore to different trainees' needs. We use a case vignette to illustrate how a clinical situation might be formulated at each of these levels.
In this article, Insoo Kim Berg was interviewed on solution-focused therapy, and Steve de Shazer joined in the interview. During the interview, Berg discussed the evolution of her work and its application to various populations.
Psychiatric nurses must look for new approaches to behavior change as managed care environments influence the nature of theirpractice. Solution-focused therapy is one model of brief therapy that can offer interventions congruent with nursing's core values. The focus of this article is the analysis of one key solution-focused therapy intervention, solution-oriented questions. Three of the most frequently used questions, the miracle, exception, and coping questions, are described in detail Concepts underlying the use of these questions are explored, and a case example is presented.
The historical origins of the case formulation approach to assessment and treatment are described and its role in clinical practice and research discussed. It is argued that treatment based on individual case formulations should not be precluded from clinical trials. The empirical evidence for the reliability and efficacy of case formulation is reviewed. The evidence that an idiosyncratic case formulation approach to treatment has any advantage over a standard protocol is equivocal; however, the studies that have been carried out are under powered and potentially suffer from a Type II error. The standard procedure for case formulation is briefly described and the argument advanced that this method of clinical assessment should be soundly based upon empirical evidence and hypothesis testing and not on speculation. Three modifications are suggested to the current practice of case formulation. These are: 1) the conceptualization of dysfunctional systems in the maintenance of clinical problems; 2) the historical background of a clinical problem should be described in terms of vulnerabilities and epidemiological evidence-base; and 3) the pivotal role of social behaviour and context should be emphasized and accommodated in a formulation. The advantages of a case formulation, in providing an understanding of the maintenance of clinical problems, in providing an integrated approach to intervention are outlined.
This study tested the hypothesis that clinicians can agree on two aspects of a cognitive-behavioral case formulation: the client's overt problems and underlying cognitive mechanisms. To test this hypothesis, 46 clinicians listened to part or all of an initial interview for two anxious, depressed clients and then listed each client's overt difficulties and rated each client's underlying cognitive mechanisms. When groups of five clinicians were considered, clinicians showed moderate agreement in listing overt problems, and, except for one type of belief (dysfunctional attitudes) for one client, high agreement on ratings of underlying cognitive mechanisms.
The closing decades of the twentieth century saw a dramatic shift from institutional to community-based care for the mentally ill. This paper describes a study of the social representation of mental illness by mental health professionals working in Britain and France during this time of major policy change. Such professionals play a vital social role in translating policy directives into practical work with laypeople, yet their representations are relatively under-researched. Data in this study derive from semistructured interviews on the nature of mental ill-health and mental health work conducted with a multidisciplinary sample of professionals (N=60). Consonant with community care policies, analysis suggests that professionals conceptualize mental ill-health and its treatment in social rather than medical terms. However, uncertainty characterizes many aspects of their representations. This is associated with eclectic working practices combining multiple strategies derived from diverse theoretical traditions. The changing policy context appears to have augmented this representational uncertainty. Psychodynamic perspectives are more influential amongst French practitioners compared with their British counterparts. The study highlights how social representations held by 'intermediary' groups reflect their interface between scientific and lay spheres. The role of power and the function of social representations in reconciling sources of tension and ambiguity associated with this unique social position are discussed.
The use of Peplau's interpersonal nursing theory with people suffering from serious mental disorder.
To describe Peplau's theory and its application using a case study.
Author's own clinical work.
Peplau's theory can be used to help patients resolve symptoms by guiding them through the steps of observation, description, analysis, formulation, validation, testing, integration, utilization.
Since Peplau outlined her perceptions of psychiatric/mental health nursing in (1952) interpersonal relationships has been considered by many as the core of practice. In the intervening period of almost a half century many researchers and theorists have endeavoured to develop and integrate Peplau's framework into day-to-day nursing activity. However, more recently, as a result of the fusion between the professional nursing agenda and the wider political agenda, the importance of interpersonal relationships and the individuality of psychiatric/mental health nursing is being questioned. This questioning is represented in the debate about the aetiology of mental illness, the choice of research methods to determine treatment outcomes and by association the role and value of the psychiatric/mental health nurse. This paper will focus on the interpersonal nature of psychiatric/mental health nursing and explore possible research approaches aimed at explicating its core. Attention will be given to the necessity of using pluralistic methodology in order to do so.
This paper illustrates the application of Hildegard Peplau's Interpersonal Theory of Nursing to group psychotherapy. The phases of the nurse-patient relationship, including orientation, identification, exploitation and resolution, are described as they relate to group psychotherapy, and clinical examples are presented. The clinical examples also demonstrate the patient's movement in group therapy through the steps of the learning process: observation, description, analysis, formulation, validation, testing, integration and utilization. Finally, the roles of the nurse including stranger, resource person, teacher, leader, surrogate and counsellor are described as they occur in group psychotherapy.
Psychiatric diagnosis: some implications for mental health nursing care This article explores some of the functions of psychiatric diagnosis and the implications this has for the mental health nursing care that service users receive. It proposes that because a psychiatric diagnosis often fails to describe the individual's experience of mental distress it can be regarded as a categorization process that, while not necessarily intentionally, serves to maintain oppressive power relations within society. It does this by establishing and maintaining the parameters of normality and abnormality in a manner that reflects particular gender, culture and class biases. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders will be used to illustrate some of the inherent biases in the diagnostic process. Mental health nursing practice needs to demonstrate an awareness of the power relations inherent in any diagnostic process and make attempts to redress these at both the individual and sociopolitical levels. If mental health nursing practice is a patient-centred partnership, as many of our nursing standards suggest, then nursing's focus should be on the patient's experience rather than the psychiatric diagnosis with which the experience is attributed. Mental health nurses need to turn to service users to learn how best to help.
The therapeutic relationship is a concept held by many to be fundamental to the identity of mental health nurses. While the therapeutic relationship was given formal expression in nursing theory in the middle of the last century, its origins can be traced to attendants' interpersonal practices in the asylum era. The dominance of medical understandings of mental distress, and the working-class status of asylum attendants, prevented the development of an account of mental health nursing based on attendants' relationships with asylum inmates. It was left to Peplau and other nursing theorists to describe mental health nursing as a therapeutic relationship in the 1940s and later. Some distinctive features of colonial life in New Zealand suggest that the ideal of the attendant as the embodiment of bourgeoisie values seems particularly unlikely to have been realized in the New Zealand context. However, New Zealand literature from the 20th century shows that the therapeutic relationship, as part of a general development of a therapeutic discourse, came to assume a central place in conceptualizations of mental health nursing. While the therapeutic relationship is not by itself a sufficient basis for professional continuity, it continues to play a fundamental role in mental health nurses' professional identity. The way in which the therapeutic relationship is articulated in the future will determine the meaning of the therapeutic relationship for future generations of mental health nurses.
Depression is widely acknowledged to be the major factor implicated with suicide, an enormous financial cost on the economies of western countries and a source of intense despair for millions of people around the world. A steady stream of articles are published both in popular, generic and specialist nursing journals that illustrate the potential of cognitive behavioural therapies in the treatment of depression. Should these therapies be restricted for use by registered therapists or do the techniques have a wider application? The marketing of these approaches for use by nurses prompted a review of the purported strengths and weaknesses of these approaches in comparison with other possible alternatives. Many mental health nurses in community settings already use cognitive behavioural approaches with clients. Here it will be argued that several of the recognized strengths of cognitive behavioural approaches lend themselves to incorporation in nurse-patient interactions in varied in-patient settings by nurses who spend protracted periods of time with depressed patients but lack formal therapist qualifications and do not consider themselves counsellors.
Psychiatric nursing care is based on an interpersonal process that relies on the therapeutic use of self in the service of patient care. Despite acknowledgment of the importance of the relationship, there has been little attention paid to the knowledge embedded in psychodynamic theory that can provide a basis for understanding the nurse-patient relationship. This paper argues that nurses need to understand and apply such theory if they are to pursue the assertion that the relationship with the patient is the foundation of their practice. The authors discuss the essential components of psychodynamic theory and their application to nursing as well as the possible reasons for the loss of interest in such theory.
An important aspect of nursing theory development has been the adaptation of theory from other disciplines within the metaparadigm of nursing. This eclectic approach to theory development enhances the broad humanistic theory base on which effective, professional nursing practice is based.
The aim of this article is to describe the process of integrating two distinct psychotherapeutic approaches into one coherent mental health nursing intervention for the treatment of affective symptoms in older adults. Guidelines for using this integration process in psychiatric mental health nursing clinical practice are presented and illustrated through the case study approach.
A case study is presented describing a clinical situation in which life review techniques were used to enhance the outcomes of a cognitive therapy experience for older adults enrolled in outpatient psychotherapy treatment for acute adjustment disorder with an affective component.
The advanced practice psychiatric mental health nurse who approaches psychotherapeutic interventions with older adult clients from an eclectic approach can achieve successful outcomes by having a clear understanding of (i) the dynamics of the various psychotherapeutic approaches, (i) the skill level of the practitioner, (iii) the psychosocial sophistication of the client, and (iv) the pathology being treated. In addition, active involvement by the client in a treatment process that matches his/her psychosocial skill and coping resource level will contribute to effective resolution of pathology. A cognitive therapy approach supplemented by life review techniques is an excellent example of an effective, eclectic treatment approach of affective disorders in older adults.
In this paper, two mental health nurses who have experienced long academic careers reflect on the way their own thinking and teaching about the human condition has changed over the course of their careers. Three major paradigms that have attempted to explain the human condition, the biological sciences, psychodynamic theory, and socio-cultural theory, are discussed. It is argued that no single approach is sufficient to address the complexities of providing care within psychiatric and mental health nursing. It is further argued that the integration of these perspectives has not been well considered or articulated in practice. The authors conclude that the arguments presented in this paper are likely to challenge people's loyalties to a particular perspective of the human condition.
Interpersonal psychotherapy (IPT) is well-recognized for the treatment of depression with many efficacy trials supporting its use. However, there is little discussion of its use in mental health nursing practice. This paper explores how IPT can be a useful intervention for mental health nursing practice and demonstrates the process of IPT with reference to a case study. The case study illustrates how IPT facilitates a shift for one woman from a passive subject position to a more self-assertive one. This shift was facilitated by identifying how she was constructing herself in relation to others by utilizing tactics of passivity and avoidance of conflict. The development of more satisfying subject positions facilitated an improvement in mood and recovery from depression.
Limited research on the reliability of cognitive case formulation suggests cognitive therapists can agree about clients' presenting problems but show poor agreement about the inferential aspects of formulation. There has been no research examining the quality of practitioners' case formulations. This study assessed whether participants with different levels of experience could produce reliable cognitive formulations using a systematic cognitive therapy case formulation method: the J. Beck Case Conceptualization Diagram. As part of continuing education workshops on cognitive case formulation, 115 mental health practitioners were given the same case description and asked to provide case formulations. Inter-rater agreement and agreement with a "benchmark" formulation provided by J. Beck were measured. The results showed that participants were able to agree with each other and with the benchmark on most descriptive aspects of the formulation but rates of agreement decreased for aspects of the formulation requiring greater levels of theory-driven inference. Based on definitions and measurements of the quality of cognitive formulations derived in this study, the quality of formulations ranged from very poor to good, with only 44% rated as being at least good enough. Both reliability and quality of case formulations were associated with levels of clinical experience and accreditation status. Implications for training and supervision are discussed.
This article explores some of the functions of psychiatric diagnosis and the implications this has for the mental health nursing care that service users receive. It proposes that because a psychiatric diagnosis often fails to describe the individual's experience of mental distress it can be regarded as a categorization process that, while not necessarily intentionally, serves to maintain oppressive power relations within society. It does this by establishing and maintaining the parameters of normality and abnormality in a manner that reflects particular gender, culture and class biases. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders will be used to illustrate some of the inherent biases in the diagnostic process. Mental health nursing practice needs to demonstrate an awareness of the power relations inherent in any diagnostic process and make attempts to redress these at both the individual and sociopolitical levels. If mental health nursing practice is a patient-centred partnership, as many of our nursing standards suggest, then nursing's focus should be on the patient's experience rather than the psychiatric diagnosis with which the experience is attributed. Mental health nurses need to turn to service users to learn how best to help.
An ethnonursing method was selected to explore and describe nursing support relationships, from the perspectives of recipients, within the mental health subculture. Data sources consisted of three semi-structured client interviews (n = 14) and field notes. When nurses were described as nice and friendly, and validated the client as a person by listening, three overlapping phases of development emerged from the data. These included: a glimmer of help, exploring and problem solving, and saying goodbye. When clients had negative experiences with nurses, they felt a lack of trust towards nurses and felt that their feelings were left unexplored. As a result, the relationships deteriorated. Deterioration began immediately in the first phase called withholding, and continued through the phases of avoiding and ignoring, and struggling with and making sense of. These findings raise healthcare providers' awareness about developing and deteriorating nurse-client relationships, and support the value of the therapeutic relationship as an instrument to restore and promote clients' health.
Comparative inter-country research which identifies similarities and differences in the work of mental health nurses in different social and political contexts is an important means of determining how changes in health care systems could lead to better outcomes for patients.
This study sought to compare aspects of the work of nurses in US and UK mental health care settings. Nurses were invited to reflect on aspects of their role including identifying the most and least satisfying elements of their work and suggesting ways in which it could be improved.
A 12-item questionnaire, comprising closed and open-ended questions, based on the literature and the authors' own experiences of mental health nursing practice, was piloted and subsequently distributed to respondents in both countries.
The US nurses tended to be more willing to accept a wider range of clients than their UK counterparts, although they had lower expectations of their clients' likelihood of recovery. Both groups of nurses felt that being part of a team and having direct contact with clients were the most satisfying aspects of their work, while administration was the least. Although both US and UK nurses utilised a variety of intervention models, it would appear that Cognitive Behavioural Therapy was the favoured model for the majority of nurses.
The implications of these findings for the work of nurses and mental health care services in the UK and US, and the purpose, nature and need for future international comparative research are discussed.
This paper acknowledges the concept of the unconscious in psychiatric discourse and explores the importance of this for mental health nursing practice. Mental health nursing practice has always been strongly influenced by psychiatric discourse because of its dominance in the clinical setting. The most recent edition of the American Psychiatry Association's Diagnostic and Statistical Manual has signalled that the concept of the unconscious is re-emerging in psychiatric discourse. This re-emergence provides the opportunity for mental health nurses to re-affirm or develop their psychotherapeutic skills in the nurse-patient relationship. The psychotherapeutic relationship could focus on ways for the patient to find meaning in their lives that recognize and value difference and multiple ways of being.
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