'Not Left in Limbo': Service User Experiences of Mental Health Nurse Prescribing in Home Care Settings.

Prescribing in mental health nursing in the Republic of Ireland is still an unusual occurrence and despite an uptake in prescriber training, this does not often translate to practice. Recent Irish research, however, has identified that nurse prescribing when offered, is perceived to enhance care and offer better delivery of services. Since the legislation was introduced in the Republic of Ireland to enable nurses and midwives to prescribe in May 2007, there are now 1,123 nurses registered to prescribe medication. Mental health nurses, however, do not tend to be a priority when it comes to training in prescribing; in the UK it took two years after nurse prescribing was rolled out to extend the scheme to mental health nursing. Although nurse and other professional perspectives explored this topic, there is limited research specifically detailing the experience of service users in long term care who are prescribed by mental health nurse practitioners in a home care setting. This research follows a qualitative exploratory research design using thematic analysis to explore service user (n = 12) experiences of mental health nurse prescribing. The following four themes emerged from the analysis: 'empowerment and trust'; 'person-centered care'; 'time and flexibility' and 'collaborative approach'. Results indicate a positive and rich experience of nurse prescribing, which facilitate a more trusting, holistic and autonomous therapeutic relationship. Future research looking at other issues relating to medication including reduction and support for coming off where appropriate is recommended.

An embodied distress: African asylum seekers' experiences of mental health difficulties while awaiting an asylum outcome in Ireland.

The mental health of asylum seekers has attracted significant interest and examination. Quantitative studies have consistently indicated that asylum seekers experience mental distress at a higher rate than both host populations and their refugee counterparts. Qualitative insight into asylum seekers' embodied experience of mental distress is limited. This qualitative narrative study aimed to explore African asylum seekers' everyday embodied experiences of mental distress. Sixteen semi-structured one-to-one interviews were conducted with African asylum seekers who had experienced mental distress and were receiving mental health care services in Ireland. Narrative data were analysed using a holistic analysis framework of narrative form and content. Participants described their everyday endurance of relentless rumination, shame, self-loathing, anger, and mistrust, and of becoming demoralised and hopeless. Study findings indicate that asylum seekers' mental distress interweaves the physical, psychological, emotional, and social realms, thus impacting on the whole of their being. Consequences for asylum seekers include feeling anaesthetised, having a severely diminished capacity to connect and interact with their external surroundings and other people, and, for some, efforts to end their life.Examinations of, and responses to, asylum seekers' mental distress must delve beyond the confines of diagnostic categorisations and codifications of symptomology. To achieve heightened understanding and efficacious interventions, we must empathetically listen and engage with asylum seekers' narratives of distress and the socio-cultural and socio-political context they inhabit.

"Providing a complete episode of care": A survey of registered nurse and registered midwife prescribing behaviours and practices.

AIMS AND OBJECTIVES: To describe the prescribing behaviours and practices of registered nurse and midwife prescribers and to explore experiences of enablers and barriers to prescribing practices. BACKGROUND: The extension of prescriptive authority to nurses and midwives internationally has created new opportunities for them to expand their scope of practice and is of significant benefit to effective and efficient health service provision. DESIGN: Cross-sectional national survey of registered nurse and midwife prescribers. METHODS: Data were collected through an online survey between April-July 2018. A total of 84 nurse and midwife prescribers participated. The STROBE checklist was applied as the reporting guideline for this study. RESULTS: Respondents estimated that two-fifths of their consultations involved an episode of prescribing. Nurse and midwife prescribers engaged in similar prescribing behaviours spanning the range of activities from initiating new medications to ceasing medicines. The most frequently selected criterion for prescribing was clinical effectiveness. Prescribing was viewed as essential to respondents' clinical practice, allowing them to provide a complete episode of care and leading to a reduction in medication errors and reduced delays and waiting times for patients. Enablers of prescribing included knowledge, experience, education and access to continuous professional development, as well as support from colleagues and organisations. CONCLUSION: Little is known about the prescribing behaviours and practices of registered nurse and midwife prescribers. While prescribing authority enables nurse and midwife practitioners to deliver holistic care, there remain significant barriers and challenges including increased workloads, lack of continuous professional development, lack of support and overly restrictive rules and policies governing prescribing. RELEVANCE TO CLINICAL PRACTICE: Addressing the barriers identified in this study could enable more nurse and midwife prescribers to work to their full scope of practice, enabling populations to fully capitalise on the contributions of registered nurse and midwife prescribing services.

Master's level mental health nursing competencies, a prerequisite for equal health among service users in mental health care.

PURPOSE: This discussion paper aims to explore the need of a clarified definition of master's level mental health nursing competencies in terms of knowledge, skills and attitudes in a European context. Mental health service users have, in spite of their right to equal overall health, higher rates of physical illness and are more likely to experience premature death than the general population. Implementation of a holistic concept of health comprising mental, physical and social aspects of health in mental health services has previously proved to be challenging. METHODS: Master's level mental health nursing competencies in recent literature are discussed and illuminated in terms of knowledge, skills and attitudes in order to enable the promotion of equal overall health among service users in mental health services. RESULTS: The discussion show contents, values and utility of master's level mental health nursing competencies in mental health services and contribute to reduced role ambiguity by distinguishing master's level responsibilities from undergraduate nursing tasks and obligations of other professionals in mental health care. CONCLUSION: This discussion paper shapes implications for developments in master's level mental health nursing education curricula.

Barriers to midwives and nurses addressing mental health issues with women during the perinatal period: The Mind Mothers study.

AIMS AND OBJECTIVES: To explore barriers to midwives and nurses addressing mental health issues with women during the perinatal period. BACKGROUND: Perinatal mental health is considered an important public health issue with health policy internationally identifying the importance of psychological support for women in the perinatal period. Midwives and primary care nurses are ideally positioned to detect mental distress early, but evidence suggests that they are reluctant to discuss mental health issues with women during pregnancy or in the postnatal period. DESIGN: The research used a descriptive design. METHODS: A total of 809 midwives and nurses completed an anonymous, online or hard copy survey. Designed by the research team, the survey listed 26 potential barriers to the provision of perinatal mental health care. RESULTS: Participants identified organisational factors as presenting the greatest barriers. Organisational barriers included lack of perinatal mental health services, absence of care pathways, heavy workload, lack of time, lack of privacy and not seeing women regularly enough to build a relationship. Over 50% of participants identified practitioner-related barriers, such as lack of knowledge on perinatal mental health and cultural issues; lack of skill, in particular, skills to respond to a disclosure of a mental health issue; and fears of causing women offence and distress. Findings also indicated that the context of care and education influenced the degree to which participants perceived certain items as barriers. CONCLUSIONS: Midwives and primary care nurses encounter many organisational- and practitioner-related barriers that negatively impact on their ability to incorporate mental health care into their practice. RELEVANCE TO CLINICAL PRACTICE: Midwifery and nursing services need to develop strategies to address system- and practitioner-related barriers, including the development of services and care pathways, and the provision of culturally sensitive education on perinatal mental health in order to support practitioners to address issues with confidence and competence.

Preparing master-level mental health nurses to work within a wellness paradigm: Findings from the eMenthe project.

Mental health promotion remains an important component of mental health nursing practice. Supporting wellness at both the individual and societal levels has been identified as one of the key tenets of mental health promotion. However, the prevailing biomedical paradigm of mental health education and practice has meant that many nurses have not been equipped to incorporate a wellness perspective into their mental health practice. In the present study, we report on an exploratory study which details the knowledge, skills, and attitudes required by master-level mental health nurses to practice within a wellness paradigm from the perspective of three groups of key stakeholders: (i) service users and family members (n = 23); (ii) experienced mental health nurses (n = 49); and (iii) master-level mental health nursing students (n = 37). The findings, which were reported from individual and focus group interviews across five European countries, suggested a need to reorientate mental health nursing education to include a focus on wellness and resilience to equip mental health nurses with the skills to work within a strengths-based, rather than a deficits-based, model of mental health practice. Key challenges to working within a wellness paradigm were identified as the prevailing dominance of the biomedical model of cause and treatment of mental health problems, which focusses on symptoms, rather than the holistic functioning of the individual, and positions the person as passive in the nurse-service user relationship.

An exploration of clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners, in Ireland.

BACKGROUND: Clinical specialist (CS) and advanced practitioner (AP) roles have increased in nursing and midwifery internationally. This study explored clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners in Ireland. METHODS: Using a case study design, interview, observational and documentary data from postholding sites (CSs or APs employed) were compared with data from non-postholding sites (no CSs or APs employed). Interviews and observations were conducted with postholders (n = 23), and compared with data from healthcare professionals (nurses or midwives, doctors) (n = 23) in matched services. Interviews were held with Directors of Nursing and Midwifery (n = 23), healthcare professionals (n = 41), service users (n = 41) with experience of receiving care or working with postholders, and non-postholders in matched services. The data were analysed using Nvivo (Version 8). RESULTS: The findings suggest that postholders' practice appeared to differ from non-postholders' in relation to case management and service provision. Postholders were seen as having an impact on readmission rates, waiting lists/times, collaborative decision-making, continuity of care and workload management. Postholders' autonomy to manage caseloads was perceived to lead to smoother transition of patients/clients through the healthcare system. Service-users' self-reports appeared to appreciate the individualised holistic care provided by postholders. Postholders' role in facilitating person-centred care and promoting interprofessional team working, are essential elements in quality care provision and in global healthcare workforce planning. CONCLUSIONS: To meet changing healthcare demands, promote person-centred care, and improve service delivery, more specialist and advanced practice posts in nursing and midwifery should be developed and supported within healthcare.

Policy-makers' views on impact of specialist and advanced practitioner roles in Ireland: the SCAPE study.

AIM: To ascertain and explore the views held by key healthcare policy-makers on the impact of clinical specialist and advanced practice nursing and midwifery roles. BACKGROUND: Specialist and advanced practice roles are common world-wide and were introduced in Ireland in 2000. After experiencing these roles for a decade, the views of healthcare policy-makers were sought as part of a national evaluation. METHODS: A qualitative, descriptive design was used. Following ethical approval, 12 policy-makers were interviewed in 2010, using a six-part interview schedule. RESULTS: Policy-makers believed that specialist and advanced practice roles resulted in better continuity of care, improved patient/client outcomes and a more holistic approach. These clinicians were also said to be leading guideline development, new initiatives in care, education of staff, audit and policy development. They lacked administrative support and research time. Budget cuts and a government-applied recruitment moratorium were said to hamper the development of specialist/advanced practice roles. CONCLUSION: Healthcare policy-makers believe that specialists and advanced practitioners contribute to higher quality patient/client care, particularly at a strategic level. IMPLICATIONS FOR NURSING MANAGEMENT: These roles could make an important contribution to future health service developments, particularly in relation to chronic-disease management and community care, where more advanced practitioner posts are required.

Factors influencing advanced practitioners' ability to enact leadership: a case study within Irish healthcare.

AIM: To report the factors that influence clinical specialists' and advanced nurse practitioners' ability to enact their clinical and professional leadership roles; findings from the SCAPE study. BACKGROUND: The importance of leadership for specialist and advanced practitioners is highlighted in the international literature and is considered an important factor in the provision of improved patient outcomes. Despite many studies identifying the barriers in developing and integrating new specialist/advanced practice roles into health services, little is known about the factors that influence the leadership dimension of their role. METHOD: A case study design involving 23 clinical specialist/advanced practitioners working in Ireland and multidisciplinary team members working with them, was used. Data were collected using interview, observation and documentary analysis. RESULTS: Four mediating factors influence the specialist/advanced practitioner's ability to perform a leadership role, namely the presence of a framework for the professional development of the role; opportunities to act as leaders; mechanisms for sustaining leadership; and personal attributes of practitioners. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: Nursing/midwifery leaders and managers at all levels have a key role in supporting leadership potential, through countering the negative impact of professional isolation, expanding opportunities for specialist/advanced practitioners to influence policy and network with wider professional groups.

Successful research capacity building in academic nursing and midwifery in Ireland: an exemplar.

BACKGROUND: Nursing and midwifery education have comparatively recently moved into academia in Ireland. In 2002, nurse tutors who were qualified to Master's degree level assimilated into the third-level sector. Only 11 of the 35 staff (31%) in one university School held, or were undertaking, a PhD. In 2006, children's nursing and midwifery tutors also moved into third-level institutions. The culture of all assimilating tutors was focussed on teaching, rather than research. OBJECTIVES: The School set ambitious plans to develop the research abilities of all academics, setting the goal that 75% of academic staff would either hold, or be undertaking, a PhD by 2010. Objectives were also set to increase external research funding, peer-reviewed publications and conference presentations. METHODS: A combination of sabbatical leaves, student stipends and periods of reduced teaching load was introduced to provide staff with protected time for doctoral studies. Funding for conference and research expenses was provided, based on the previous year's research output of publications, conference presentations and external funding submissions. RESULTS: By October 2010, 79% of the 66 School staff either had (n=23), or were conducting (n=29), PhDs, surpassing goals set. Peer-reviewed publications and conference presentations had increased by >20% per year and external research funding totalled €6,351,101 for the previous 5 years. CONCLUSIONS: Strong research leadership, generous support and liberal encouragement can change a predominantly teaching-focussed culture to one of academic research excellence. This increase in research expertise will lead to better patient/client care and improved education of nursing and midwifery students.

Using case study within a sequential explanatory design to evaluate the impact of specialist and advanced practice roles on clinical outcomes: the SCAPE study.

BACKGROUND: The role of the clinical nurse/midwife specialist and advanced nurse/midwife practitioner is complex not least because of the diversity in how the roles are operationalised across health settings and within multidisciplinary teams. This aim of this paper is to use The SCAPE Study: Specialist Clinical and Advanced Practitioner Evaluation in Ireland to illustrate how case study was used to strengthen a Sequential Explanatory Design. METHODS: In Phase 1, clinicians identified indicators of specialist and advanced practice which were then used to guide the instrumental case study design which formed the second phase of the larger study. Phase 2 used matched case studies to evaluate the effectiveness of specialist and advanced practitioners on clinical outcomes for service users. Data were collected through observation, documentary analysis, and interviews. Observations were made of 23 Clinical Specialists or Advanced Practitioners, and 23 matched clinicians in similar matched non-postholding sites, while they delivered care. Forty-one service users, 41 clinicians, and 23 Directors of Nursing or Midwifery were interviewed, and 279 service users completed a survey based on the components of CS and AP practice identified in Phase 1. A coding framework, and the generation of cross tabulation matrices in NVivo, was used to make explicit how the outcome measures were confirmed and validated from multiple sources. This strengthened the potential to examine single cases that seemed 'different', and allowed for cases to be redefined. Phase 3 involved interviews with policy-makers to set the findings in context. RESULTS: Case study is a powerful research strategy to use within sequential explanatory mixed method designs, and adds completeness to the exploration of complex issues in clinical practice. The design is flexible, allowing the use of multiple data collection methods from both qualitative and quantitative paradigms. CONCLUSIONS: Multiple approaches to data collection are needed to evaluate the impact of complex roles and interventions in health care outcomes and service delivery. Case study design is an appropriate methodology to use when study outcomes relate to clinical practice.

Sexuality: the challenge to espoused holistic care.

Nurses, by virtue of the close relationship with patients, are in a unique position to promote sexual health and provide sexual health advice to people in their care. Although nurses espoused the ideals of person-centred and holistic care, evidence from research studies suggested that, for a number of reasons, nurses did not consciously and proactively engage with patients in relation to sexual concerns. In today health-care environment, where patients are seeking information about the impact of illness and treatments on their sexual function, nurses have a responsibility to proactively engage with patients' sexual health concerns in an informed and sensitive manner. The aim of this paper is to provide nurses with guidelines on how they might include this aspect of care within their everyday work.