Views of Mental Health Nurses on Responding to Clinical Aggression on General Wards.

The overall aim of this study was to explore the views of mental health nurses (MHNs) about their experience of responding to workplace violence (WPV) and aggression (code greys and blacks) within acute general wards. WPV continues to pose a significant source of challenge within healthcare settings despite several initiatives that have been trialled over the years. It has the potential to impact patient care and overall staff health and well-being. Nurses play a significant role in the management of WPV; hence, it is important to understand how they respond to and manage incidents of WPV. The study design was an explorative descriptive qualitative design. Data were collected through semi-structured interviews involving n = 10 MHNs working within a mental health consultation liaison team that responds to incidents of violence and aggression (codes grey and black) in acute general wards. Participants were recruited using a convenient sampling method. Data were analysed using thematic analysis. The findings of this study highlighted the following themes: (1) Patient care (subthemes: patient frustration with hospital processes, lack of time and resources); (2) Staffing skills and confidence (subthemes: lack of adequate training, inability to intervene early and communication skills); (3) Understanding patient behaviours (subthemes: it's a psychiatry problem and zero tolerance approach). The management of WPV within acute hospital settings needs to be given due attention by healthcare services. Although a number of organisations are developing measures and guidelines to manage WPV, there is still a gap in the ability of general nursing staff to properly manage such incidences. Proper attention needs to be taken to the training of staff.

Validating cognitive screening in young people with first-episode psychosis: The CogScreen protocol.

AIM: Cognitive impairments are a core feature of first-episode psychosis (FEP) and one of the strongest predictors of long-term psychosocial functioning. Cognition should be assessed and treated as part of routine clinical care for FEP. Cognitive screening offers the opportunity to rapidly identify and triage those in most need of cognitive support. However, there are currently no validated screening measures for young people with FEP. CogScreen is a hybrid effectiveness-implementation study which aims to evaluate the classification accuracy (relative to a neuropsychological assessment as a reference standard), test-retest reliability and acceptability of two cognitive screening tools in young people with FEP. METHODS: Participants will be 350 young people (aged 12-25) attending primary and specialist FEP treatment centres in three large metropolitan cities (Adelaide, Sydney, and Melbourne) in Australia. All participants will complete a cross-sectional assessment over two sessions including two cognitive screening tools (Screen for Cognitive Impairment in Psychiatry and Montreal Cognitive Assessment), a comprehensive neuropsychological assessment battery, psychiatric and neurodevelopmental assessments, and other supplementary clinical measures. To determine the test-retest reliability of the cognitive screening tools, a subset of 120 participants will repeat the screening measures two weeks later. RESULTS: The protocol, rationale, and hypotheses for CogScreen are presented. CONCLUSIONS: CogScreen will provide empirical evidence for the validity and reliability of two cognitive screening tools when compared to a comprehensive neuropsychological assessment. The screening measures may later be incorporated into clinical practice to assist with rapid identification and treatment of cognitive deficits commonly experienced by young people with FEP.

Adolescent Violence in the Home Among Youth Presenting to an Early Psychosis Service: An Exploration of Contributing Factors.

Adolescent violence in the home is a growing public health issue and remains under reported and under-researched. The focus of the present research is to investigate factors that may contribute to adolescent violence in the home, among acohort of young people with co-occurring early psychosis. Data relates to 50 young people (16 females, 33 males, 1 nonbinary) aged from 16-25 who were clients at a youth early psychosis service in Melbourne, Australia. Results from a discriminant function analysis revealed the two major contributing factors to whether someone used violence in the home, were whether a young person had a coexisting neurodevelopmental or intellectual disability and whether they used violence outside the home. The findings provide preliminary evidence that engaging in violence outside the home and the presence of a neurodevelopmental or intellectual disability may make it more likely for young people with early psychosis to use violence in the home.

A qualitative evaluation of a co-design process involving young people at risk of suicide.

BACKGROUND: Co-design is becoming common practice in the development of mental health services, however, little is known about the experience of such practices, particularly when young people are involved. OBJECTIVE: The aim of this study was to conduct a process evaluation of the co-design which was undertaken for the development of an intervention for youth and adolescents at risk of suicide. This paper briefly outlines the co-design process undertaken during a COVID-19 lockdown and then focuses on a qualitative evaluation of the experience of taking part in a co-design process. SETTING AND PARTICIPANTS: The evaluation involved young consumers of a public youth mental health service, their carers/parents and service delivery staff who had taken part in the co-design process. METHOD: This study used follow-up semistructured interviews with the co-design participants to explore their experience of the co-design process. Inductive thematic analysis was used to draw out common themes from the qualitative data. RESULTS: It was found that despite the practical efforts of the project team to minimise known issues in co-design, challenges centred around perceptions regarding power imbalance, the need for extensive consultation and time constraints still arose. DISCUSSION: Despite these challenges, the study found that the co-design provided a human-centred, accessible and rewarding process for young people, parents and staff members, leaving them with the feeling that they had made a worthwhile contribution to the design of the new service, as well as contributing to changing practice in service design. CONCLUSION: With sensitivity and adaptation to usual practice, it is possible to include young people with suicidal ideation, their parents/carers and professional staff in a safe and effective co-design process. PATIENT AND PUBLIC CONTRIBUTION: The authors would like to thank and acknowledge the young people with a lived experience and their carers who participated in the co-design process and research evaluation component of this study. We also wish to thank the clinical staff, peer workers and family peer workers who participated in this research.

Are codesigned programmes more difficult to implement? A qualitative study of staff perceptions on the implementation of a new youth mental health programme.

BACKGROUND: Codesigned interventions are becoming more common in health services and, in particular, in the design and development of mental health programmes and interventions. However, previous research has established that the transition from codesign to implementation can experience several challenges and that this transition process has received little research attention. OBJECTIVE: The aim of this study was to explore the experience of staff members charged with the implementation of a codesigned intervention for young people and adolescents at risk of suicide. SETTING AND PARTICIPANTS: Five staff members involved in the implementation of the new codesigned programme took part in semi-structured interviews. METHOD: The study involved qualitative evaluation of staff experiences during the implementation of a new child and youth suicide intervention. Interviews were analysed using reflexive thematic analysis. RESULTS: The analysis identified four themes of 'disconnect', 'operational challenges, 'service user' and 'being authentic'. 'Disconnect' captures the difficulties of implementing a codesigned programme which leads to 'operational challenges' in meeting broader expectations while ensuring the feasibility of the programme. The third theme, 'service user', captures the realisation that the young people accessing the new service were different to those involved in the codesign process. The final theme, 'being authentic', highlights how staff needed to be responsive and flexible while remaining true to the principles proposed in the codesign. DISCUSSION: This study yielded some valuable insights into the challenges around the implementation of a codesigned intervention, an under-researched area. The findings suggest that adaption of the design may be necessary, if it is not informed by implementation constraints, making it necessary for the implementation team to be well-briefed on the initial design and given plenty of time to make the necessary adjustments in a coproduction process. Limitations for the generalisation of the results include a small sample of staff and particular challenges that may be unique to this study. CONCLUSION: The present study highlights that for health services undertaking codesign approaches, appropriate time and resources need to be considered for the implementation phase of an initiative, to ensure that there is effective translation from design to implementation and that new codesigned services can be effective within operational constraints. PATIENT AND PUBLIC CONTRIBUTION: The authors would like to thank and acknowledge the young people with a lived-experience and their carers who participated in the codesign process and research evaluation component of this study. We also wish to thank the clinical staff, peer workers and family peer workers who participated in the evaluation.

Psychiatry trainee experience of working in a child and adolescent eating disorder program.

OBJECTIVES: Eating disorders are serious psychiatric conditions that affect people of all ages. Many psychiatry trainees' first and only experience with eating disorders during training is their Child and Adolescent Psychiatry (CAP) rotation. This study aimed to explore the learning experience of psychiatry trainees working within an Eating Disorder Program (EDP) during their CAP rotation. METHODS: Fifteen trainees who participated in the EDP were recruited to complete an online survey and focus groups; a thematic analysis design was used to identify themes emerging from their responses. RESULTS: Themes emerged from the trainee learning experience of working in the EDP around what they found they learnt, what aided that process, what was difficult, and recommendations for future improvement. CONCLUSIONS: This study provided insight into the trainee experience in an EDP as one example of how trainees can learn about eating disorders and one way that could inform future workforce and training initiatives.

"What makes discovery college different?" a co-produced analysis of student experiences of discovery college.

BACKGROUND: Recovery colleges are an education-based approach to supporting mental health recovery that incorporate the voice of both lived and living experience, and experience by training in their design, production, and delivery. AIMS: To understand students' experiences of attending a youth-focused 'discovery college' course. Specifically, to see whether students were satisfied with the course, whether the learning goals of the courses were met, and what students felt makes discovery college different. METHODS: A mixed methods design analysed quantitative data on students' ratings of the course and their learning goals. A co-produced thematic analysis, incorporating the voice of lived and living experience, was also conducted on students' responses to the question "what makes discovery college different?" RESULTS: Overall, students rated their experience with the course very positively, and mostly met the learning goals of courses. The co-produced thematic analysis revealed students valued the incorporation of lived and living experience in courses, the lack of power imbalance between teachers and students, and felt it was a safe space to share and learn. CONCLUSIONS: Findings support the delivery of the recovery college model within a youth setting, and highlights this as a useful initiative in engaging people from a range of perspectives in education about mental health.

Moderated Online Social Therapy for Carers of Early Psychosis Clients in Real-World Settings: Cluster Randomized Controlled Trial.

BACKGROUND: Family carers of youth recovering from early psychosis experience significant stress; however, access to effective family interventions is poor. Digital interventions provide a promising solution. OBJECTIVE: Our objective was to evaluate across multiple Australian early psychosis services the effectiveness of a novel, web-based early psychosis intervention for carers. METHODS: In this cluster randomized controlled trial conducted across multiple Australian early psychosis services, our digital moderated online social therapy for carers (Altitudes) plus enhanced family treatment as usual (TAU) was compared with TAU alone on the primary outcome of perceived stress and secondary outcomes including mental health symptoms and family variables at the 6-month follow-up. RESULTS: Eighty-six caregivers were randomized and data were available for 74 young people in their care. Our primary hypothesis that carers randomized to Altitudes+TAU would report greater improvements in perceived stress at follow-up compared with carers randomized to TAU alone was not supported, with the TAU alone group showing more improvement. For secondary outcomes, the TAU alone group showed improved mindfulness over time. Regardless of group assignment, we observed improvements in satisfaction with life, quality of life, emotional overinvolvement, and burden of care. In contrast, hair cortisol concentration increased. Post hoc analyses revealed more contact with early psychosis services in the intervention group compared to TAU alone and that improvements in perceived stress and social support were associated with use of the intervention in the Altitudes+TAU group. In this study, 80% (12/15) reported a positive experience with Altitudes and 93% (14/15) would recommend it to others. CONCLUSIONS: Our trial did not show a treatment effect for Altitudes in perceived stress. However, our post hoc analysis indicated that the amount of use of Altitudes related to improvements in stress and social support. Additional design work is indicated to continue users' engagement and to significantly improve outcomes in problem-solving, communication, and self-care. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12617000942358; https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12617000942358.

System Action Learning: Reorientating Practice for System Change in Preventive Health.

It is now widely accepted that many of the problems we face in public health are complex, from chronic disease to COVID-19. To grapple with such complexity, researchers have turned to both complexity science and systems thinking to better understand the problems and their context. Less work, however, has focused on the nature of complex solutions, or intervention design, when tackling complex problems. This paper explores the nature of system intervention design through case illustrations of system action learning from a large systems level chronic disease prevention study in Australia. The research team worked with community partners in the design and implementation of a process of system action learning designed to reflect on existing initiatives and to reorient practice towards responses informed by system level insights and action. We were able to observe and document changes in the mental models and actions of practitioners and in doing so shine a light on what may be possible once we turn our attention to the nature and practice of system interventions.

Integrating Substance Misuse Specialists in a Youth Early Psychosis Service: Increasing Mental Health Clinicians' Knowledge and Confidence.

Substance misuse and mental health disorders are commonly occurring co-morbidities in young people. This paper reports on a pilot project to embed three specialist Alcohol and Other Drug (AoD) workers to be embedded in a youth early psychosis service to upskill mental health clinicians in managing substance misuse. Evaluation of the project used a mixed methods approach. Quantitative results showed that clinical staff members' knowledge of substance misuse, knowledge of AoD treatments and services, and overall confidence in working with young people with a substance misuse issue improved following implementation of the project. Qualitative results indicated four themes which emerged: defining the role of the AoD workers; support and upskilling of the mental health staff; openness and effective communication between the embedded workers and mental health teams; and barriers to collaboration. The results provide support for the embedding of specialist alcohol and drug workers in youth mental health services.

Organizational Change in Complex Systems: Organizational and Leadership Factors in the Introduction of Open Dialogue to Mental Health Care Services.

Conventional mental health services are frequently criticized for failing to support people and communities in their care. Open Dialogue is a non-conventional humanistic approach to mental health care, which has been implemented in many different settings globally. At two Australian public health care services, implementation of the approach led to positive client outcomes and sustained organizational and clinical change. The aim of the study was to identify and explore the organizational, management, leadership and cultural factors that contributed to sustained implementation in these complex systems. We conducted nine individual semi-structured interviews of health care leaders and managers from the two sites. Transcriptions of the interviews were analyzed thematically. Leaders facilitated a gradual development of clinical and organizational legitimacy for the non-standardized Open Dialogue approach by holding the anxiety and frustration of practitioners and parts of the administration, cultivating cultural change and adaptation and by continually removing organizational obstacles.

Establishing Recovery Colleges in mental healthcare services: A Royal Commission recommendation.

Recovery Colleges are an innovative education-based approach to support mental health recovery that, following the recent Royal Commission, will have to be established in every area mental health service within the state of Victoria. This paper describes the rationale, benefits and some of the key considerations to successfully establish Recovery Colleges. The establishment of Recovery Colleges has the potential to drive culture change within mental health services and embed recovery orientation within service provision as well as engaging service users in their own recovery journey. There are significant challenges, however, in implementing the collaborative, co-produced model within the constraints of a publicly funded mental health clinical service. This paper considers some of the practice implications for public mental health services in developing and integrating Recovery Colleges. The paper, like everything we do at the Recovery College, is co-produced and co-authored - in this case, by a lived experience expert, a medically trained expert and a research/writing expert.

Case Study Demonstration of the Potential Acceptability and Effectiveness of a Novel Telehealth Treatment for People Experiencing Gambling Harm.

The evidence base for internet therapies is building but little is known yet about the acceptability and effectiveness of providing telehealth online in a group format for the treatment of gambling disorders. Therefore, this uncontrolled, real-world study aimed to evaluate the feasibility and effectiveness of providing evidence-based treatment in a group format using an online platform. This innovative approach to treatment of people experiencing gambling harm was developed during the COVID pandemic so that gamblers could access evidence-based treatment from their homes. A closed group treatment program was developed using telehealth, enabling gamblers to come together weekly to engage in a treatment program based on behavioral therapy using cue exposure. Four online gamblers who met the criteria for Gambling Disorder were recruited from a gambling help service. A case report evaluation methodology was used to gain an in-depth understanding of the effectiveness of this approach to treatment. Treatment was conducted weekly over 12 months. All participants engaged with the program and after completing treatment participants no longer met the criteria for a Gambling Disorder, were abstinent for 12 months post treatment and achieved improved life functioning. This program provides preliminary evidence that providing treatment online in a group setting can be an acceptable and effective model in the delivery of treatment for clients unable to attend face-to-face clinics or preferring telemedicine as an option for treatment delivery. These findings warrant further exploration through a larger randomized controlled study.

Single session family therapy for beginners: what difference does it make to psychiatry registrars to participate in family sessions in front of and behind the screen?

OBJECTIVE: Current competencies required for fellowship of the RANZCP require psychiatry registrars to have experience in working with clients across all age groups, as well as working with families and the client's wider network, however gaining this experience is not always easy for trainees. This paper reports on the experience of participating in Single Session Family Therapy (SSFT) during registrar training as a different modality for learning. METHOD: An online survey was conducted with fourteen registrars who had participated in SSFT during their child and adolescent rotation. Qualitative and simple quantitative data were collected and analysed. RESULTS: Participating in SSFT during training was initially daunting, but had a positive effect on trainees, including influencing some towards focussing their future sub-specialisation in the child and youth area. Experience came through learning by doing, and seeing change. Registrars learnt about: understanding the role of the family; teamwork; technical skills; and gained confidence. CONCLUSIONS: Opportunities for trainees to participate in SSFT enables powerful learning beyond what can be taught in the classroom. Such opportunities may enhance registrars' perceptions of family work, and may positively influence decision about future sub-specialisation.

How the experience of different non-acute bed-based mental health services reinforces the need for tailored stepped care.

Objective Stepped care as a model of provision of mental health services has been frequently described from clinical or health administration perspectives, but less is known about the consumer perspective of stepped models of care. Method Qualitative interviews were undertaken with 18 consumers across a range of residential mental health services in Melbourne, Australia. Interviews were designed to help understand consumers' needs and experiences in navigating different services to meet their needs at different times in their mental health journey. Results Consumers experience fluctuations in their mental state that are best responded to by having access to a range of services, as well as to services that can respond flexibly to changing needs. Consumers do not necessarily progress through stepped care in a linear or step-up, step-down fashion. Conclusion Stepped care services need to be flexible in accommodating people along a continuum of care and responsive to where the consumer is at on their journey, rather than predetermining the trajectory of care. What is known about the topic? Stepped care has been identified as a critical component of comprehensive mental health care, bridging the gap between primary care and acute mental health services. The components of effective stepped care models have been broadly articulated, but the experience of moving through different components of care in response to changing needs has not previously been well described. What does the paper add? This paper presents consumer perspectives on a model of stepped care that is designed to respond flexibly to the changing needs of consumers, rather than representing a linear model of progress through the system. What are the implications for practitioners? Mental health services are increasingly grappling with provision of care to the 'missing middle': people with chronic mental illness yet not in an acute phase requiring in-patient hospital care. This paper presents a model of stepped care that responds to the fluctuating needs of consumers.

Establishing a COVID-positive mental health ward: an Australian-first case study.

OBJECTIVE: Managing mental health patients during the COVID-19 pandemic has been a global challenge. Current workforce arrangements tend to separate those skilled in caring for highly infectious medical patients from those whose specialism is in managing co-morbid mental health, substance misuse and/or behaviours of concern, including potential non-compliance with community or health care directives. This paper reports an innovative service development through the emergency establishment of a temporary COVID-positive mental health ward in response to a local outbreak in Melbourne. METHOD: A case study of service reorientation is presented, examining barriers and enablers to effective care of co-morbid mental illness, addiction and COVID-19. RESULTS: Establishing a skilled multidisciplinary workforce across mental health and infectious disease is the most important consideration in optimising care. Other issues included suitable physical space, security arrangements and inter-disciplinary communication. CONCLUSIONS: The paper holds insights for managing mental health care during potential future infectious disease outbreaks across the country.

The COVID PIVOT - Re-orienting Child and Youth Mental Health Care in the Light of Pandemic Restrictions.

The COVID pandemic required significant changes in the provision of youth mental health services during the period of lockdown/stay at home orders. Things which were identified as changing significantly during this period included: service via telehealth; working from home, split teams (to reduce infection risk), and social (physical) distancing. An online survey of clinicians was conducted involving both closed and open ended questions. Service staff identified significant benefits from the changes to the way services were delivered as well as some impediments and challenges. Advantages in the new way of working revolved around the flexibility of the virtual service, with appointments online enabling families to more easily overcome issues of transport, work commitments, childcare and disruption to routines and timing. The online platforms also enabled some family members to participate who otherwise might not have been able to come to appointments in person. Disadvantages included where there were issues with availability and access to appropriate technology or private spaces, or when the young person was very young, very unwell, unstable, isolated or at higher risk. This study suggests that telehealth and flexible working arrangements have become an essential new element in the clinicians' toolkit to be offered either alone or as a supplement to in person interventions.

How Do Mental Health Nurses Define Success? A Comparative Study of Bed-Based and Community-Based Services.

Nursing is the single largest professional group within both hospital and community mental health care services, however the role of mental health nurses in under-defined. The nursing workforce is also coming under increasing pressure from internal and external requirements, and nurses themselves are on the frontline of providing patient care in what can be a risky and unpredictable workplace environment. This project explored via interview the ways in which mental health nurses experience and reflect on their personal and professional feelings of nursing success. Participants were 19 nurses who were employed in a range of bed-based and community mental health services in inner south eastern Melbourne. This study complies with the Consolidated Criteria for Reporting Qualitative Research (COREQ). The findings of the project align with existing evidence from the literature. Factors which helped mental health nurses feel successful included: therapeutic success; good teamwork; targeted education; and feedback. Barriers to success included: patients/clients do not engage or recover; poor communication amongst staff; lack of psychological safety in the workplace; and lack of respect from management. Nurses in community settings were more able than nurses in bed-based settings to: make effective use of clinical supervision; make use of targeted training and educational offerings; and practice therapeutically and holistically. Project results offer an opportunity to understand nurses' motivations and reward systems. Better understanding of these issues can improve the way mental health care services manage their workforce planning, maintain staff personal wellbeing, increase staff retention and ultimately improve patient/client care.

Supporting the Support Network: The Value of Family Peer Work in Youth Mental Health Care.

Reported rates of mental illness continue to climb amongst young Australians. In a family environment the carers of these young people play a highly influential role in their recovery process, however this responsibility can also have significant emotional, financial and health impacts on carers. This paper details the findings of an evaluation project examining the impact and effectiveness of a newly developed and implemented Family Peer Support Work model. Benefits were found which included: family care-givers receiving emotional support and empathy; reduced stress, loneliness, isolation and stigma; bridging between the family and the clinical care team; helping families to navigate through the complexities of the care system; and connecting families to other services. Clarity on role definition for the FPSWs evolved over the course of implementation along with a clearer articulation of the model of care and emergent knowledge on useful elements of training, ongoing professional development, mentoring and wellbeing.

Development of a Lived Experience-Based Digital Resource for a Digitally-Assisted Peer Support Program for Young People Experiencing Psychosis.

This paper describes the creation of a web-based digital resource designed for tablet computer use during peer work sessions to structure discussion about recovery in early psychosis. The resource consisted of a series of videos featuring young people who have used early psychosis services discussing how they navigated issues in their own recovery. A participatory process was used to create the resource. Researchers held a series of collaborative development workshops with early psychosis service users, peer workers, other mental health practitioners, and academics. These were used to derive a framework of recovery processes relevant to young people experiencing psychosis, which was considered as useful areas of discussion within a peer work relationship. A semi-structured interview guide based on this framework was then used in video-recorded interviews with young people in recovery from psychosis. Footage was edited into 14 videos and organized into six final themes: My Journey, Self-Care, Connections, My Identity, Life, and Mental Health. The combined expertise of young mental health service users, peer support workers, mental health practitioners, and digital mental health researchers throughout the development process enabled the creation of tailored digital resource for peer work in an early psychosis service.