Moral distress in the critical care air transport nurse.

BACKGROUND: Moral distress in healthcare providers occurs when the perceived right action cannot or is not taken and results in a loss of moral integrity. Critical Care Air Transport (CCAT) nurses are elite U.S. Air Force (USAF) clinicians who provide healthcare during transport of injured military members. CCAT nurses are vulnerable to physical and psychological stressors, including fatigue, multiple traumas, limited resources and ethical dilemmas. PURPOSE: The purpose of this study was to explore moral distress in USAF CCAT nurses. METHODS: Using interpretative hermeneutic phenomenology, we described the lived experience of moral distress in 15 CCAT nurses. FINDINGS: Seven themes emerged to describe the CCAT nurses experiences of moral distress. These include: Not Prepared, Agent of Healing or Agent of Harm, Live or Let Die, Robbing Peter to Pay Paul, Ever Decreasing Circles, Cultural Dissonance, and Incongruence with Colleagues. DISCUSSION: This study highlighted both similarities and differences in moral distress than those described previously in the literature. Military unique situations contribute to the experience of moral distress in USAF CCAT nurses. These findings will guide future research aimed at understanding and mitigating moral distress effects in military nurses and other healthcare providers.

Assessment of Suicide Risk: Validation of the Nurses' Global Assessment of Suicide Risk Index for the Portuguese Population.

BACKGROUND: Mental health problems, particularly depression, are a major risk factor for suicide. Currently, there is no way to predict, with 100% accuracy, who will make a suicide attempt, but during a clinical interview, it is possible to assess the risk presented by each patient based on the investigation of risk and protective factors. The assessment of these factors helps health care professionals make decisions on the interventions to put into practice, thus contributing to reducing risk. The use of suicide risk assessment tools, properly validated for the population under consideration facilitate communication and information gathering, with clinical nurse specialists in mental health playing an important role. METHOD: Because of the shortage of suicide risk assessment tools properly validated for the Portuguese population, it was our aim to translate, adapt and validate the Nurses Global Assessment of Suicide Risk (NGASR) for the Portuguese population. In this study, a questionnaire was applied to a sample of 109 patients with depressive symptoms and risk factors for suicidal behaviors. RESULTS: The analysis of the results showed that most sample participants had a very high risk of suicide. The study of the psychometric properties of the NGASR showed moderate internal consistency and good content and criterion validity. Content validity, obtained through a panel of experts, was consensual. The NGASR index had good criterion validity, showing strong correlation with the SIQ, BDI and DASS-21 (R=0.830, p<0.05). The principal components analysis showed 6 factors, and the 15 predictive variables explained 66.92% of the total variance. CONCLUSION: These results are similar to those obtained in studies conducted in other countries and, therefore, the application of the NGASR is believed to be reliable for the Portuguese population.

Unearthing the Theoretical Underpinnings of "Green Care" in Mental Health and Substance Misuse Care: Theoretical Underpinnings and Contemporary Clinical Examples.

The concept of "Green Care" can increasingly be found in mental health and addictions literature and some Psychiatric/Mental Health Nurses are practicing in facilities that base their approach on some or all of the underpinning theoretical elements of Green Care. However, Green Care is not yet widely considered to be part of mainstream psychiatry. Unearthing and articulating its theoretical underpinnings and clinical applications may further advance its legitimacy. Accordingly, this article identifies four principal theoretical elements of Green Care: Connectedness; Contact with Nature; Benefits of Exercise; and Occupation/Work as Therapeutic, each of which is explored and articulated by drawing on relevant literature.

Mental health nurses responding to suffering in the 21st century occidental world: accompanying people in their search for meaning.

Much of contemporary health and mental health practice pays little attention to suffering, and when it does, invariably suffering is conflated with pain. Within such views, the health care practitioner ought to be concerned with removing or stopping the suffering as, for many parts of the occidental world at least, suffering is regarded as antagonistic to the pursuit of happiness. However, it has been recognized since ancient times that the experience of suffering can give rise to growth. This view sees suffering as an inevitable aspect of the human condition and experience; as something that might need to be endured, minimized, relieved, explored for meaning and maybe even learned from. The former conceptualization of suffering leaves little, if any, room for the sufferer to be to be proud of his suffering and to consider it ennobling rather than degrading, and such views are highly congruent with the increased pathologizing of 'everyday life' and with that, the inexorable proliferation of pharmacological 'treatment'. Accordingly, we assert that there is a clear need for Psychiatric/Mental Health nurses to re-think their views of suffering and consider how they might help the person discover meaning in the experience; how they might accompany the individual on his/her suffering journey. We therefore identify a range of approaches and interventions that Psychiatric/Mental Health nurses can use when attempting to help those experiencing mental health-related suffering.

Nursing Leadership, Missing Questions, and the Elephant(s) in the Room: Problematizing the Discourse on Nursing Leadership.

To expose inconsistencies and contradictions in the nurse leadership literature ("text"), this article adopts a deconstructive approach and draws upon the work of Derrida in examining the text or discourse. What is almost entirely missing in the literature are articles that ask difficult, searching questions that challenge some of the taken-for-granted truths or maxims about nursing leadership. The current examination of the literature, described in this article, shows: (a) a lack of convergence of the literature and health care/nursing organizations concerning leadership, (b) a conflation of nursing leadership with managerial or administrative positions, and

Towards Effective Management in Psychiatric-Mental Health Nursing: The Dangers and Consequences of Micromanagement.

Micromanagement refers to a management style that involves managers exercising control over team members, teams, and also organizations, particularly in relation to the minutiae or minor details of day-to-day operations. While there is no single reason why some managers may choose to micromanage, many micromanagers exhibit similar behavioral traits, a consequence of perfectionism and/or underlying insecurities. In the culture of high performance that characterizes many contemporary mental health contexts, micromanagement also provides one way by which teams can be driven to achieve targets. However, over time, micromanagement leads to reductions in staff morale, creativity, and productivity; and increases in staff turnover. This paper provides an overview of micromanagement, including points of consideration for managers interested in reflecting on their management styles, and strategies for mental health nurses who find themselves working for a micromanager.

Respect in mental health: reconciling the rhetorical hyperbole with the practical reality.

Although there is a high degree of consensus in the existing literature regarding the importance of respect in mental health care, a realistic appraisal suggests that there is something of a disconnect between what is espoused in policy documents and what actually occurs in practice. As a result, this article seeks to explore and advance our understanding of the phenomenon of respect in mental health care and draws on real practice situations to illustrate this schism. To this end, the authors present three case studies that focus on the following: "use of seclusion," "respecting professional boundaries," and "horizontal workplace violence." The authors advance the, perhaps for some, provocative argument that it is relatively easy to write/speak about respect, while the reality of communicating respect to others is more difficult, challenging, and makes significant demands on the individual psychiatric/mental health nurse.

Providing meaningful care: learning from the experiences of suicidal young men.

Little is known about young suicidal men's preferences for care. Using a broad interpretive approach, we interviewed 36 formerly suicidal young men in a study addressing the development and provision of mental health services. Our analysis yielded three core categories: widening access and bolstering proactive outreach, on becoming a man, and equipping young men for future challenges. Collectively, these categories suggest key features and processes of appropriate service configuration and clinical care: (a) services that reach out proactively serve to encourage young men's initial and ongoing engagement; (b) care delivered over the long term ensures a necessary focus on a meaningful future life; (c) mental health professionals (MHPs) are centrally involved alongside significant others, including those with personal experience of suicide; and (d) the development of a vital interpersonal connection is based on MHPs actively communicating their empathy, open-mindedness, and interest in a young man's unique biography.

Nurse migration in an increasingly interconnected world: the case for internationalization of regulation of nurses and nursing regulatory bodies.

Psychiatric/Mental Health nursing has a long history of professional self-regulation; nevertheless, interest in how governments protect consumers of health care from poor or dangerous practice(s) is on the increase. Correspondingly, there have been calls, in several parts of the world, for greater watchfulness and due diligence from regulatory bodies. Mindful of the concept of "globalization" and the unequivocal data regarding the significant increase in the migration of nurses, it is difficult to ignore/deny the reality of an increasingly mobile and connected international nursing workforce. However, the extant literature also indicates the existence of significant disparities between countries and even states/provinces within countries as to the enforcement of professional regulation. What this means is that decisions made by one regulatory body can have a direct impact on the standard(s) of nursing quality and practice in a country on the opposite side of the world. As a result, the authors attempt to advance the debate that there is a clear need to reconcile these positions, and they introduce the argument for the creation of an international oversight body. Using case study material, the relevant theoretical and policy literature in this area (such as it is), and by drawing on examples of analogous oversight bodies from other areas, we draw attention to the need to create a genuinely international body for the oversight of nurse regulation.

Challenging normative orthodoxies in depression: Huxley's Utopia or Dante's Inferno?

Although there appears to be a widespread consensus that depression is a ubiquitous human experience, definitions of depression, its prevalence, and how mental health services respond to it have changed significantly over time, particularly during recent decades. Epistemological limitations notwithstanding, it is now estimated that approximately 121 million people experience depression. At the same time, it should be acknowledged that the last two decades have seen the widespread acceptance of depression as a chemical imbalance and a massive corresponding increase in the prescription of antidepressants, most notably of selective serotonin reuptake inhibitors (SSRIs). However, questions have been raised about the effectiveness and iatrogenic side effects of antidepressants; related questions have also been asked about whose interests are served by the marketing and sales of these drugs. Accordingly, this article attempts to problematize the normative orthodoxy concerning depression and creates a "space" in which an alternative can be articulated and enacted. In so doing, the article finds that the search for a world where the automatic response to depression is a pharmacological intervention not only ignores the use of alternative efficacious treatment options but may also inhibit the persons' chance to explore the meaning of their experience and thus prevent people from individual growth and personal development. Interestingly, in worlds analogous to this pharmacologically induced depression-free state, such as utopias like that in Huxley's Brave New World, no "properly conditioned citizen" is depressed or suicidal. Yet, in the same Brave New World, no one is free to suffer, to be different, or crucially, to be independent.

Listening as a method of addressing psychological distress.

AIMS: This paper discusses the values of therapeutic listening and ways that emotional difficulties can impact palliative nurses' abilities to provide psychological care. BACKGROUND: Recent literature indicates that providing psychological care can burden some healthcare professionals including nurses; who may lack the necessary competencies or organizational resources to carry out their roles. EVALUATION: References drawn from the databases: all EBM reviews, British Nursing INDEX, CINAHL, PSYCH INFO and MEDLINE and EMBASE are discussed. KEY ISSUES: Psychological care is considered critical to providing holistic care. Yet the literature suggests engaging in such work makes emotional demands on the professionals attempting to carry it out and is associated with psychological difficulties including burnout. CONCLUSION: Clinical supervision can help reduce the distress caused by emotionally charged situations. Thoughtful clinical supervision can also contribute to safe and effective health care. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing would benefit from understanding more about the effects on healthcare professionals of repeated exposure to emotionally charged situations and benefits that clinical supervision can offer to health care.

Transposing Yallom: recognizing and understanding group dynamics in a Canadian online diploma in psychiatric nursing.

Given the historical association between psychiatric/mental health (P/MH) nursing education and group formats, and the recent shift to online education, one might expect to see a well developed literature that focuses on P/MH nurse education in online group settings; yet this is patently not the case. This paper attempts to redress this omission by drawing on educational material produced in a regional online diploma in psychiatric nursing. After reviewing the relevant extant literature, it adopts Yallom's seminal work and transposes this into online group settings. Examples of postings drawn from this programme are then used to help recognize and understand online group dynamics. The authors conclude that group dynamics are as much a part of online P/MH nurse education as they have been for 'traditional', face-to-face, educational programs, albeit manifest, expressed and encountered in different ways. Secondly, acknowledging the existence of these group dynamics creates the need for a new skill set, or maybe the transposition of an existing skill set for P/MH nursing educators. Thirdly, examination/analysis of student online postings (virtual case studies) enables the tentative epistemological transposition of face-to-face group dynamics into the online version.

Psychometric properties of the Italian version of the Nurses' Global Assessment of Suicide Risk (NGASR) scale.

AIM: People with mental disorders have higher risk of suicide compared to the general population. Assessment of risk factors can help nurses reducing suicidal risk. The Nurses' Global Assessment of Suicide Risk scale (NGASR) has proven valid and reliable in supporting the nursing evaluation of suicidal risk in different studies. The aim of the study was to examine the psychometric properties of the NGASR in the Italian population. METHODS: We translated the scale and administered it to a sample of 121 patients admitted to acute psychiatric wards. RESULTS: The Content Validity Index-Scale (CVI-S) was 96.7%, the correlation with the Scale for Suicide Ideation (SSI) score was high (r=.98, p<.001). Inter-rater reliability (rho=.97, p<.001), and test-retest stability (p=.96) were satisfactory. Factor analysis pointed out 5 factors and the 15 items of the NGASR-ita explained 61.29% of total variance. Of the 121 subjects assessed upon admission, 25.62% had average or higher suicidal risk. DISCUSSION AND CONCLUSIONS: The use of valid screening tools in support of Suicide risk assessment is recommended. The NGASR-ita is a valid and reliable tool, suitable for nursing assessment of suicidal risk in the acute psychiatric setting.

Review of predictors of suicide within 1 year of discharge from a psychiatric hospital.

Previous research has shown that suicide risk is highest in the year after people have been discharged from a psychiatric hospital. As such, identifying predictors of suicide within this time frame is important. Results from a systematic database search showed that all significant suicide predictors--those found in more than one study--could be grouped into factors related to suicidality, patient care factors, and demographic and psychopathological factors. Increased knowledge of suicide predictors for this particularly high-risk time, identified in this review, can help inform prevention and intervention efforts that may significantly reduce suicide rates.

Feeling our way in the dark: the psychiatric nursing care of suicidal people--a literature review.

Psychiatric/Mental Health nurses have a long history of being front-line carers of suicidal people, and yet the international epidemiological literature, methodological problems notwithstanding, suggests that contemporary care practices for suicidal people have much room for improvement. As a result, this paper focuses on several areas/issues of care of the suicidal person, and in so doing, critiques the extant literature, such as it is. This critique illustrates that there is a disconcerting lack of empirically induced theory to guide practice and even less empirical evidence to support-specific interventions. The paper concludes, accepting the axiomatic complexity and multi-dimensionality of suicide, and the undeniable fact that suicide is a human drama, played out in the everyday lives of people, that for Psychiatric/Mental Health nurses, caring for suicidal people must be an interpersonal endeavor; and one personified by talking and listening.

Creating a space for recovery-focused psychiatric nursing care.

Within contemporary mental health-care, power relationships are regularly played out between psychiatric nurses and service users. These power relationships are often imperceptible to the practicing nurse. For instance, in times of distress, service users often turn to or/and 'construct' discourses, beliefs and knowledge that are at odds with those which psychiatric nurses rely on to inform them of the mental status of the service user. The psychiatric nurse is in the position to impose knowledge onto service users, usually in concurrence with 'traditional or bio-psychiatry', without realizing or failing to acknowledge that the service user may have an alternative explanation of his/her mental health problems/experiences. In this paper, practice examples, based on the experiences of the four authors (from within and outside of services), are used to illustrate this 'hidden' power relationship. The authors use Foucault's ideas about: (i) government; (ii) the knowledge/power nexus and resistance; (iii) and his analytic tool of genealogy to help unravel this paradox within psychiatric nursing practice. The authors also use the emerging discourse of recovery as an alternative (and challenge) to 'traditional bio-psychiatry' and consider the implications for psychiatric nursing practice.

Salvation or damnation: deconstructing nursing's aspirations to professional status.

AIM: This paper will deconstruct the rationale(s) for aspiring to professional status in nursing. BACKGROUND: It is argued that 'transformative nursing leaders' must transition from operational to strategic aspects, such as considering the question of whether or not nursing should move towards professional status. METHOD: This paper examines documented outcomes arising out of professional status and considers whether or not these are contrary to the central tenets of nursing's underpinning philosophy and practice axioms. The outcomes scrutinized are: compensation, respect and recognition, political influence and clout, the consumer movement and the gender issue. FINDINGS: A carte blanche aspiration for professional status is irreconcilable with some of nursing's central tenets. However, there are benefits that nurses should pursue. CONCLUSION: Aspiring to professional status by adopting the normative orthodoxies and dominant discourse of our medical colleagues actually serves to reinforce and maintain nurses in a mostly subservient role. IMPLICATIONS FOR NURSING MANAGEMENT: In place of adopting the gendered views of professional status, nurses and clients might be better served by the creation of a parallel discourse; one where the central and underpinning values of nurses and clients are seen as equal, though different to the values of the current dominant discourse.

Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (Part one).

Suicide remains as a distinct global public health problem, and the reduction of rates continues to be a major concern of the governments of many countries; this has given rise to the creation of national suicide prevention strategies. As with any other mental health-related policy document, it behoves mental health nurses to juxtapose these against the realities of their practice and educational needs. To this end, this two part paper draws on national suicide prevention strategy policy directions that appear to speak directly to the practice and/or educational needs of mental health nurses and critiques these. The direction indicating more training in risk assessment is perhaps questionable given that this is already by far the most developed area of the suicidology-focused literature and that our increased knowledge has risk factors that have not so far produced widespread reductions in suicide rates. Furthermore, this additional attention, at least in part, reflects the clear move towards more coercion and control in international mental health policy. The direction indicating that practitioners should use evidence-based interventions to prevent suicide is laudable although difficult to reconcile with practice realities given that there is currently a distinct lack of evidence-based interventions for working with people who are suicidal. As a result, this paper offers some suggested amendments to the national suicide prevention strategies, and the second part of this paper focuses on three more policy directions.

Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (part two).

Suicide remains as a distinct global public health problem and the reduction of rates continues to be a major concern of the governments of many countries. This two-part paper focuses on national suicide prevention strategies; it highlights common policy directions that appear to speak directly to the practice and/or educational needs of mental health (MH) nurses and juxtaposes these against the realities of their practice and educational needs. Part one focused on two of these policy directions, whereas part two concentrates on the following policy directions: (iii) initiatives to reduce access to lethal means; (iv) improve surveillance systems; and (v) training for caregivers to improve delivery of effective treatments. The paper argues that while being mindful of the physical environment and its associated access to means, the national suicide prevention policy literature should consider reflecting that this should be an adjunct to the more central aspects of MH nursing care of people who are suicidal. Further, it is argued that the suicide policy literature should consider replacing 'improving surveillance systems' with 'improving the ability and capacity of MH nurses to engage with people who are suicidal'. Lastly, the paper asserts that the suicide policy literature might consider refining the policy direction on additional training to indicate the need for additional post-graduate (post-basic) education and training in care of the person with suicidal tendencies, which includes dialectical behavioural therapy; the work emanating from the University of Toronto; and the skills, attitudes, and knowledge perhaps captured with the terms, engagement, co-presencing, and inspiring hope.