"It's a Big Family Here." Becoming and Belonging in a Service Providing Employment-Related Support for People with Mental Health Problems: An Interpretative Phenomenological Analysis.

The impact of employment for individuals with mental health problems is complex. However, research suggests that when support is provided for accessing employment and gaining roles and skills that are valued by others, a positive effect can be seen on recovery. Employment-related support can take many forms and there is a need for further research into the experience of accessing different kinds of services. The current paper examines the lived experience of 11 people participating in a UK social enterprise providing work experience, training, and skills development for those with mental health problems. Although 'sheltered', the organisational ethos strongly emphasised service-user empowerment, co-production, equality with staff, provision of valued social roles and person-centred support. Phenomenological analysis revealed that participants valued a sense of belonging and authentic relationships within the service, whilst being given the opportunity to rediscover an identity that may have been lost because of their mental health problem. However, participants also discussed how, although the service improved their self-value, some feared the 'real world' outside of the service and were unsure whether they would be met with the same support. Tensions between field dominant approaches in supported employment and the experiences and values of the participants are explored. We argue that the findings highlight the importance of a nurturing working environment and the value for recovery of a range of meaningful roles, beyond competitive employment.

Understanding the role of spirituality in providing person-centred care.

An awareness of the concept of spirituality is integral to the provision of person-centred holistic care. However, the nurse's ability to provide spiritual care is often impeded by time pressures and the prioritisation of clinical tasks. Confusion about the meaning of spirituality and its relationship to religion may also compound the challenges involved in providing spiritual care, and nurses often feel ill-equipped to address this area of care. This article discusses the challenges associated with the concept of spirituality, and describes the competencies and personal qualities that nurses require to achieve spiritually competent practice. It also explains the concepts of availability and vulnerability, which can support the personal development required for nurses to become spiritually competent.

Mental health nurses' understandings and experiences of providing care for the spiritual needs of service users: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Addressing spiritual issues to maintain a sense of hope, meaning and purpose can be an important aspect of mental health care which goes beyond simply providing facilities for religious observance. Expressions of spiritual need from service users can potentially be confused with symptoms of mental ill health. Little is known about how mental health nurses understand or provide this aspect of care for service users. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: An understanding from the mental health nurse perspective of how mental health nurses understand and care for service users' spiritual needs, and what influences their practice in this area. Ideas about how education and opportunities for good practice in this area might be advanced. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need more education and guidance as well as supportive team and management cultures so that they feel comfortable and able to deliver this important aspect of care. Abstract Introduction Mental health nurses have a professional obligation to attend to service users' spiritual needs, but little is known about specific issues related to provision of care for spiritual need faced by mental health nurses or how nurses understand this aspect of care and deliver it in practice. Aim/Question To explore mental health nurses' ́understandings of spiritual need and their experiences of delivering this care for service users. Method A qualitative study was conducted in one NHS mental health service. Interviews were undertaken with seventeen mental health nurses practising in a variety of areas. Results Four themes were generated from thematic analysis of data in the template style: Expressing personal perspectives on spirituality; Expressing perspectives on spirituality as a nursing professional; Nursing spiritually; and Permeating anxiety (integrative). Discussion Participants had complex understandings of spiritual need and evident anxieties in relation to this area of care. Two different approaches to nursing spiritually are characterised as (a) pragmatic (concerned with procedural aspects of care) and (b) spiritually empathetic. Mental health nurses were uncertain about the acceptability of attention to spiritual issues as part of care and anxious about distinguishing between symptoms of mental ill health and spiritual needs. Implications for practice Educational experiences need to emphasise both pragmatic and empathetic approaches, and work needs to be organised to support good practice.

Spiritual Dimensions of Nurse Practitioner Consultations in Family Practice.

Purpose of Study: To explore the spiritual dimensions of nurse practitioner consultations in primary care through the lens of availability and vulnerability. Design of Study and Methods Used: A hermeneutic phenomenological enquiry exploring the spiritual dimensions of primary care consultations consisting of two interviews per participant over an 18-month period was conducted with nurse practitioners in the United Kingdom. A purposive sample of eight nurse practitioners were recruited and interviewed. Interviews were fully transcribed and analyzed thematically. Findings: Participants identified that spirituality can be difficult to conceptualize and operationalize in practice. Participants articulated the meaning of spirituality and gave examples of when they had witnessed a spiritual dimension in practice. Key themes included how nurse practitioners conceptualize spirituality, the context for spirituality to be integrated into care, and the importance of spirituality as an aspect of holistic care. The concepts of Availability and Vulnerability were used intentionally as a lens in the study to explore whether these concepts and approaches to practice could enhance integration of spirituality into practice. Conclusion: Knowledge and understanding regarding spirituality in nurse practitioners consultations in primary care has been uncovered. A framework for operationalizing spirituality has been developed.

A questionnaire-based study of attitudes to spirituality in mental health practitioners and the relevance of the concept of spiritually competent care.

In the light of the increasing recognition of the relevance of spirituality in person-centred, holistic care, this study examines the attitudes of a convenience sample of mental health practitioners, including nurses, to the concepts of spirituality in general and in clinical practice. A series of 5-point Likert-style items assessed two key domains of spirituality in everyday life (SEDL) and spirituality in practice (SIP). The questionnaire was derived from one previously used with healthcare educators (including nurses). Each item was scored from 1 point (strongly disagree) to 5 points (strongly agree). Additional information about how far practitioners believed spirituality had been integrated in their education and how much they believed that spirituality related to religion was also ascertained. Three further items, not part of the main questionnaire, dealt with respondents' views of spirituality competent practice, in the light of a description provided as part of the questionnaire. Data were collected from 104 respondents. Standard statistical procedures, including reliability analyses, were applied to the data. Respondents who viewed spirituality to be distinct from religion, or a place of worship, were likely to place a higher value on spirituality in everyday life, while respondents who experienced the integration of spirituality within their preregistration training and/or clinical education were likely to place a higher value on the place of spirituality in practice. The possible reasons for these associations are discussed in the light of the importance of spiritual care as a part of person-centred, holistic practice.

Spirituality in nursing practice.

Spirituality is an important aspect of holistic care that is frequently overlooked. This is because of difficulties in conceptualising spirituality and confusion about how it should be integrated into nursing care. This article explores what is meant by spirituality and spiritually competent practice. It examines attitudes to spirituality, describes factors that might affect the integration of spirituality into nursing care and offers practical guidance to equip nurses to incorporate spirituality into their practice.

Critical flicker fusion threshold: a potentially useful measure for the early detection of Alzheimer's disease.

Critical Flicker Fusion Threshold (CFFT) is a psychophysical threshold and, in psychological terms, it is regarded as a measure of information processing capacity. CFFT has previously been shown to be a valid and reliable measure in young healthy volunteers and it also has a long history of use as a psychopharmacological measure in this group. Furthermore, the test satisfies many of the requirements of an 'ideal' measure for monitoring change, especially in a psychopharmacological context. Despite this, CFFT has been neglected as a research tool in elderly and Alzheimer's disease (AD) populations and was therefore investigated further in this regard. CFFT in community-based healthy elderly subjects was normally distributed, but CFFT and ascending and descending thresholds were not significantly correlated with age. The difference between ascending and descending thresholds was, however, significantly correlated with age and this relationship appeared to be due almost entirely to a change in the descending threshold. In addition, descending thresholds were found to be significantly greater than ascending thresholds in healthy elderly subjects. In contrast, patients with AD were found to have significantly lower CFFT and descending scores compared with healthy elderly subjects. Interestingly, descending thresholds were significantly lower than ascending thresholds in the patient group, a feature that may be a characteristic of AD. Mean CFFT and ascending and descending thresholds were found to have a high test-retest, split-half and inter-rater reliability, in addition to being significantly correlated with a number of psychometric measures, clinical scales and neuropsychological instruments commonly used to assess patients with AD. CFFT is a quick and simple measure to administer and patients had no difficulty completing the test. Because the measure is a psychophysical threshold, it is free from educational and cultural bias and there are no floor or ceiling effects. From the results of this work, CFFT appears to be a useful research tool in AD. It may be a suitable measure for monitoring cognitive change over time, either in community studies of AD or a clinical trial context, but further work is required. The technique might also contribute to the early detection of AD. This application would be particularly important because it would enable effective pharmacotherapies to be started early during the course of the illness before neuronal damage is too advanced and this would have significant benefits for patients. Copyright 2000 John Wiley & Sons, Ltd.

Healthcare lecturers' perceptions of spirituality in education.

AIM: The aim of this research was to identify healthcare teaching staff's understanding of spirituality, how their understanding may shape teaching practice and how this may contribute to the documented issues around incorporating spirituality into patient assessment and care. METHOD: A mixed-method, small-scale explorative online survey was used. FINDINGS: Several perceptions and practices were identified that led to a better understanding of the obstacles to teaching in this area. Suggestions were made about how to shape teaching spirituality to improve patients' experience and ensure spirituality is integrated more fully into assessment and care. CONCLUSION: This study brought a better understanding of obstacles to integrating spirituality into teaching for healthcare lecturers and offered some ideas on how to best address these obstacles.

The impact of location on satisfaction with dementia services amongst people with dementia and their informal carers: a comparative evaluation of a community-based and a clinic-based memory service.

BACKGROUND: The development of effective medication for the treatment of Alzheimer's disease led to an expansion in the use of memory clinics ther clinic-based services for the delivery and monitoring of the drugs. In contrast, there is an increased emphasis on providing home and community based service delivery for a range of illnesses including dementia. METHODS: This paper reports the findings of an evaluation study comparing a clinic-based and a community service. A convenience sample of 10 service users and carer dyads took part in in-depth qualitative interviews. Service users were diagnosed with mild to moderate dementia of Alzheimer's type. Interviews were recorded, transcribed and subsequently analyzed using template analysis. RESULTS: Service users and carers were satisfied with both services, with determinants of satisfaction differing between the two services. Issues relating to the location and spatial design of services, comfort, familiarity, communication with staff, and ease of use are highlighted as important determinants of satisfaction amongst service users and their carers. CONCLUSION: This study has implications for person-centred care practices in service delivery and for the future design of mental health services for people with dementia.

Pharmacological management of behavioural and psychological disturbance in dementia.

Behavioural and psychological symptoms in patients with dementia are common, distressing and often difficult to manage. This review evaluates a range of drugs commonly used to manage these symptoms including antipsychotics, anticonvulsants, antidementia drugs and antidepressants. The risks and benefits of individual treatments are discussed and the relatively poor evidence base and need for further research is highlighted.

Psychotropic drug use in older people with mental illness with particular reference to antipsychotics: a systematic study of tolerability and use in different diagnostic groups.

OBJECTIVE: The objective of the study was to provide observational clinical data on psychotropic drugs used in older people with mental illness. METHODS: This was an observational, single-centre, one-week prevalence study of psychiatric symptoms, disorders and psychotropic drug use in older with mental illness cared for by the South West people Yorkshire Mental Health NHS Trust (Wakefield Locality), UK. The clinical assessment included completion of the Psychosis Evaluation Tool for Common use by Caregivers. RESULTS: A total of 593/660 older patients with mental illness (mean +/- SD age, 76 +/- 8.1 years were assessed. 44.5% had dementia (excluding vascular dementia) and 33.7% had a mood disorder. Of the total, 20.4% did not receive CNS active medication. Of those receiving CNS active medication approximately half (51.3%) took antipsychotics and 46.2% antidepressants. Of 304 patients taking antipsychotics, 87% took only one medication. However, patients with schizophrenia and related disorders were significantly more likely to be prescribed two or more antipsychotics (p < 0.001). Risperidone was the most frequently prescribed antipsychotic (n = 136, 44.7%). Risperidone doses were significantly lower for patients with dementia and mood disorders than with schizophrenia (p < 0.002). Side-effects from antipsychotics were significantly greater in patients with schizophrenia, suggesting a dose-related effect. Risperidone appeared to be well tolerated in all patients with no evidence of cerebrovascular side-effects in patients taking it. CONCLUSIONS: Psychotropic drugs were commonly used by older people in contact with mental health services. The doses of antipsychotics used in dementia and affective disorders were significantly lower than in schizophrenia. Risperidone was the most commonly used drug in all diagnostic groups including dementia. Despite a relatively large numbers of patients receiving risperidone in this naturalistic study, no serious side-effects were reported or identified. In this paper we focus our findings on antipsychotics in the light of recent advice from the Committee on Safety of Medicines (UK).

Antipsychotic prescribing in older people.

Antipsychotic medications have made a significant contribution to the care of the mentally ill people over the past 50 years, with good evidence that both typical and atypical agents are effective in the treatment of schizophrenia and related conditions. In addition they are widely used to good effect in other disorders including psychotic depression, dementia and delirium. Both typical and atypical agents may cause severe side-effects and, in the elderly in particular, there is an increased propensity for drug interactions. If used with care, antipsychotics are usually well tolerated, especially the atypical drugs. Although antipsychotics are effective at reducing psychotic symptoms their limitations should be recognised. They do not 'cure' the underlying illness, and the management of psychotic and behavioural symptoms must take into consideration treatment of physical illness as well as psychosocial interventions. In addition, the antipsychotic effect may take one to two weeks to be evident so doses should not be increased too rapidly. Often small doses are effective in the elderly if they are given sufficient time to work. As our understanding of the mechanisms of psychosis improves it is hoped that new drugs will be developed with novel mechanisms of action with improved efficacy and reduced side-effects. There are several drugs in development, some sharing similarities to currently available agents whilst others have novel mechanisms of actions involving glutamate and nicotinic receptors. Pharmacogenetics is also likely to be increasingly important over the next few years. As the genetic basis of many psychiatric disorders becomes more clearly established it is likely that drugs specifically designed for particular sub-groups of receptors will be developed. Finally, although the pharmacological treatment of psychotic disorders in younger people has been given considerable attention, there is a paucity of good quality research on antipsychotic drug use in older people. There is a need to redress this balance to ensure that the prescribing of antipsychotics in older people is evidence based.

The scope for qualitative methods in research and clinical trials in dementia.

In the evaluation of drugs, the randomised double-blind placebo controlled trial is the 'gold standard'. This method, based on a positivist paradigm, answers questions about efficacy and side-effects of treatments that are accepted as valid, reliable and generalisable, provided the study is well designed and properly conducted. In contrast, qualitative research methodologies, originating from the social sciences, embrace a variety of approaches, including phenomenological and other paradigms. Within clinical and health services research, qualitative approaches view the world more subjectively, acknowledging that the researcher is part of what is researched, focusing on meanings and understanding of experience, rather than on what can be reduced to quantitative measures. They can develop new ideas through induction from data, rather than confirming or refuting hypotheses. Qualitative methods have improved our understanding of the experiences of people with dementia and, if used alongside clinical trials, could be used to improve the relevance of outcomes to patients, compliance and user involvement. They could also possibly generate new measures of efficacy and effectiveness in severe dementia.

Critical Flicker Fusion Threshold in patients with Alzheimer's disease and vascular dementia.

BACKGROUND: Critical Flicker Fusion Threshold (CFFT) is a psychophysical threshold and in psychological terms is regarded as a measure of information processing capacity. The test has previously been shown to be a valid and reliable measure of CNS functioning in patients with Alzheimer's disease and may be a useful as a screening measure for the early detection of Alzheimer's disease (AD). METHODS: Consecutive referrals to the Wakefield Memory Clinic who met DSM-IV criteria for AD or vascular dementia (VaD) were invited to take part in the study. A range of neuropsychological tests and CFFT were administered to the two groups using standardised protocols and the ability of these various tests to distinguish between the two conditions was investigated. RESULTS: Forty-six patients were included in the study. Of the various tests, only the descending component of CFFT and word fluency were significantly different in the two groups. In addition, the descending threshold had a sensitivity of 83% and a specificity of 69%. CONCLUSION: CFFT could be useful as a screening instrument for early AD when combined with other measures and could facilitate the decision to commence antidementia treatment at an early stage. Further longitudinal work is needed to establish this.