'No health without mental health': where are we now?

Mental health services are under unprecedented pressure with overwhelming referrals and a current waiting list of 1.2 million people of all ages. The cross-government White Paper 'No health without mental health' was launched 12 years ago detailing the importance of wellbeing services in the creation of mentally healthy communities through health promotion and illness prevention. While primary care, community services and psychiatry are pivotal in the treatment of mental Illness/disorder, mental health care per se is on a continuum, and a great deal of work can be undertaken in communities by wellbeing services to prevent avoidable referrals. This paper proposes a broad framework of education and training for wellbeing/positive mental health services, primary and community care, and nurses working in Community Mental Health Treatment Teams and Home Treatment Teams to ensure all those working with potentially vulnerable adults and children are regulated and meet national standards for mandatory mental health education and training.

Management of work stress and burnout among community nurses arising from the COVID-19 pandemic.

The COVID-19 pandemic has increased workload demands for many NHS staff including those working in the community. Nurse managers can make a difference by being authentic leaders, nurturing a supportive organisation where the workload is managed participatively and self-kindness is legitimate. Unfortunately some staff may experience burnout and this article presents a personal management plan to address the symptoms of burnout and aid recovery, although it cannot promote a total recovery if the cause of the symptoms remains unaddressed.

Reducing restrictive practice: a pertinent issue for children's services.

The reduction of restrictive practice has gained momentum in mental health services and it is now becoming evident in mainstream adult services. There remains confusion as to the definition of 'restrictive practices' across all sectors of health care, including the difference between 'restrictive practices' (such as attitudes of control, limit setting and unnecessary ward rules) and 'restrictive interventions' (including physical, chemical or mechanical restraint). This article highlights the relevance of restrictive practice to children's nursing and argues that the principles apply across all health provision. Acts of restrictive practice may result in challenging behaviour, or even restrictive interventions, strategies to minimise both restrictive practice and subsequent acts of challenging behaviour are explored. Behavioural support plans adopting a bio-psycho-pharmaco-social approach have been shown to be effective in both mental health and adult nursing and are recommended for use in children's nursing.

COVID-19: it happens to nurses too-a case study.

The COVID-19 pandemic will have long-term ramifications for many patients, including those who work in the NHS and have been victims of the disease. This short case study describes the journey of an emergency department (ED) charge nurse who contracted COVID-19 and was hospitalised in the intensive care unit (ICU). Post-discharge, he experienced a multitude of physical and mental health complications, which ultimately impacted on each other. Therefore, a bio-psycho-pharmaco-social approach to care is recommended from admission through ICU, discharge and beyond. From this and other narratives, it appears that COVID-19 patients are not adequately followed up after ICU discharge, something that must be considered going forward.

Mental health impact of admission to the intensive care unit for COVID-19.

The pandemic caused by Covid-19 has long term ramifications for many, especially those patients who have experienced an intensive care unit (ICU) admission including ventilation and sedation. This paper will explore aspects of care delivery in the ICU regarding the current pandemic and the impact of such on the mental health of some of these patients. Post discharge, patients will be returning to a very different community incorporating social distancing, and in some cases, social isolation and/or shielding. Many may experience a multitude of physical and mental health complications which can ultimately impact upon each other, therefore a bio-psycho-pharmaco-social approach to discharge, case management, risk assessment and positive behavioural support planning is recommended.

Rapid tranquillisation: an issue for all nurses in acute care settings.

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

Biopsychopharmacosocial approach to assess impact of social distancing and isolation on mental health in older adults.

It is impossible to predict or comprehend the impact of the ongoing COVID-19 pandemic. The UK Government's advice for vulnerable people, including older adults, to move towards self-isolation and social distancing is likely to reduce rates of transmission, the risk of severe illness and the impact on the acute health services. Although justified and necessary, this process of isolation is likely to have a negative impact on the mental health of these vulnerable groups, especially older people. It will become increasingly important for community health professionals to assess subtle changes in older persons' mental health, as the duration of this period of isolation remains unclear. The biopsychopharmacosocial model provides one method of assessing mental health and planning health and social care needs. This article hopes to guide community health professionals through the specifics of this assessment model in relation to the growing COVID-19 pandemic.

The use of positive behaviour support plans in mental health inpatient care: A mixed methods study.

WHAT IS KNOWN ON THE SUBJECT?: There is a drive to use positive and proactive approaches to mental health care to reduce the use of restrictive practices such as seclusion and restraint. Positive behaviour support plans have been used successfully to do this in learning disability services, and in England, it is now a regulatory requirement that anyone with challenging behaviour should have an individualized behaviour support plan. However, positive behaviour support plans specifically have not been evaluated as part of routine mental health care and mental health nurses' and relatives' attitudes towards them are unknown. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This evaluation of positive behaviour support plans in routine mental health inpatient care found that they had not been widely implemented or completed as intended. Barriers to the use of the plans included confusion among nurses and relatives around the principles of positive behaviour support, including how, when and for whom the plans should be used, difficulties in being able to describe the function of a patient's behaviour and lack of engagement with relatives and patients. Nevertheless, nurses and relatives valued the plans, in particular for their potential to facilitate holistic care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: To use the plans successfully, mental health nurses will need training to understand fully the rationale behind the positive behaviour support approach and will need to engage more with relatives and patients. Commitment to the approach from the whole care team and organization will be needed to implement the plans consistently for all patients. Abstract Introduction An international drive is to minimize restrictive practices in mental health care. Positive behaviour support plans (PBSPs) help staff prevent behaviour which would require restrictive intervention. Originating in learning disability services, data within mental health care are limited. Aims To evaluate PBSPs within a mental health inpatient service; understand mental health nurses' and relatives' attitudes to them; and understand the barriers and facilitators for their use in routine mental health care. Methods Mixed methods-quality ratings and interviews with relatives and nurses. Results Positive behaviour support plans were poorly implemented. Relatives and nurses valued the potential of PBSPs to facilitate holistic care, though no relative had contributed to one and not every eligible patient had one. Barriers to their use included confusion around positive behaviour support, including how, when and for whom PBSPs should be used, and difficulties describing the function of a behaviour. Discussion The potential of PBSPs to improve mental health care is recognized. However, there are barriers to their use which should be addressed to ensure that PBSPs have been properly implemented before their impact on patient care can be assessed. Implications for practice Mental health professionals implementing PBSPs should engage with relatives and patients, gain organizational commitment and ensure that those involved understand fully the positive behaviour support approach.

Reducing restrictive practice in adult services: not only an issue for mental health professionals.

Reducing 'restrictive practices' is an issue of national importance, pertinent to all NHS sectors, yet there is poor awareness of the issue in mainstream adult services. Such practices potentially restrict a person's rights to choice, self-determination, privacy and freedom. Challenging behaviour is often the result of unmet needs, communication difficulties or diagnostic overshadowing, but there is a common misconception that patients exhibit such behaviours because of their impaired intellectual abilities or mental health problems. This article seeks to raise awareness of restrictive practices and suggest the way forward. It highlights the importance of good de-escalation skills, which, if adopted early in therapeutic relationships, may help reduce the occurrence of challenging behaviours and situations. Behavioural support plans that adopt a biopsychopharmacosocial approach (BPPS) detail a range of interventions for managing challenging behaviours. Tailored support that follows a BPPS approach could reduce incidents of challenging behaviour, reduce costly observation, improve the patient experience and protect the patient's liberty.

Development of a competency tool for adult trained nurses caring for people with intellectual disabilities.

AIM: To develop and test a competency assessment tool for adult trained nurses caring for people with intellectual disabilities in hospital. BACKGROUND: The report 'Death by indifference' in 2007 highlighted inadequate care given to people with intellectual disabilities in hospital. This study sought to develop and test a competency assessment tool for adult trained nurses in the care of this patient group. METHODS: A review of the literature informed the topic guide for focus groups (n = 4) with experienced adult trained nurses, learning disability nurses and people with intellectual disabilities (n = 25). Expert interviews (n = 29) were conducted to identify emergent themes. A draft competency assessment tool was reviewed by an expert panel (n = 5) and tested within a convenience sample (n = 34; response rate 28%) at a local district general hospital across several clinical specialities. RESULTS: The participants considered themselves to be either 'novice' or 'competent' across most items. The tool was then redrafted and minor amendments made. 'Little or no knowledge' or 'novice' was reported in areas such as consent, diagnostic overshadowing and management of self harm. CONCLUSION: Use of the competency assessment tool will support assessment of current levels of knowledge and skills and inform educational provision of the workforce. IMPLICATIONS FOR NURSING MANAGEMENT: Use of the competency assessment tool will inform nursing management of skill levels and educational need.

A mixed methods study to develop and pilot a competency assessment tool to support midwifery care of women with intellectual disabilities.

BACKGROUND: Recent reports have highlighted the poor quality of health care received by people with intellectual disabilities (otherwise known as 'learning disabilities') in the United Kingdom (UK). UK Confidential Enquiries into maternal deaths have highlighted adverse pregnancy outcomes for women with intellectual disabilities and need for timely and appropriate clinical care. OBJECTIVES: To develop and test a competency assessment tool to support midwifery care of women with intellectual disabilities. DESIGN: A mixed methods study. SETTING: Large inner city maternity unit. PARTICIPANTS: Midwives and key experts in intellectual disabilities, maternity policy and midwifery education. METHODS: Phase one comprised a systematic narrative review of the literature. Evidence identified informed phase two which included focus groups and interviews. Emergent themes informed the development of a competency assessment tool which was piloted in phase three. RESULTS: Phase one: Four primary research papers and two systematic reviews met the review inclusion criteria. Support to develop parenting skills of women with intellectual disabilities was highlighted as was the need to optimise organisation of maternity services. No studies specifically considered midwifery competencies to support women with intellectual disabilities. Phase two: 23 midwives attended three focus groups and individual interviews were conducted with national leaders in intellectual disability (n=6) and midwifery policy and education (n=7). Themes identified included need for individualised care provided by a known midwife, the importance of effective communication skills and need for clear knowledge and understanding of the legislative framework relevant to intellectual disability. Phase three: A convenience sample of 60 midwives was asked to participate in a pilot study to test the tool, 46 (77%) of whom responded. Thirty midwives (65%) felt competent in their ability to recognise intellectual disability and 37 (80%) competent or expert in understanding women have the right to be offered choice and make informed decisions. A high proportion (n=40, 87%) reported little or no knowledge regarding consent issues. CONCLUSION: Work to inform timely and appropriate care of women with intellectual disability has been neglected in the UK maternity services. Use of a tool could aid assessment of midwifery competencies to support women with intellectual disability and highlight where further midwifery education and development are needed. Evidence of optimal care for women with intellectual disabilities and their families across the continuum of pregnancy and birth is required.

Overcoming ignorance and stigma relating to intellectual disability in healthcare: a potential solution.

AIM: To propose a strategy for overcoming stigma and discrimination against people with intellectual disabilities within healthcare. BACKGROUND: Evidence of poor healthcare for those with intellectual disabilities resulted in an independent inquiry. The subsequent report has charged healthcare organizations to address current organizational failings. EVALUATION: The origins of discriminatory practices in health services and the evidence of persisting poor care and stigmatization of this patient group despite UK Government policy are set out. KEY ISSUE: The stigmatization and resulting discrimination of people with intellectual disabilities persists. CONCLUSION: In addition to investment in core training, organizational change is needed to bring about change and a reduction in health inequality. IMPLICATIONS FOR NURSING MANAGEMENT: The development of a new framework for nursing is recommended with leadership at all levels of healthcare so that people with intellectual disabilities and their families can expect to receive high quality care in all healthcare settings.

Meeting the needs of people with intellectual impairment in primary care.

People with intellectual impairments are treated within the mainstream NHS including primary care with little support from specialist services. There are communication issues for primary care staff in relation to access of services and the assessment of health needs for this vulnerable group of individuals. Primary care staff do not always feel equipped to support people with intellectual impairment and need training in order to do so.

All preregistration students should develop skills in learning disabilities.

In the light of ongoing service developments and government legislation it is important that preregistration nurses from all branches have the opportunity to develop their confidence and skills in the care of people who have learning disabilities. This article outlines the development of strategies employed by one institute of higher education in order to reflect the principles of "Valuing People" from a health perspective in non-learning disability nursing programmes. The particular challenges that have been encountered in the implementation of these strategies over the last 3 years are discussed, as are issues faced in the evaluation of the effectiveness of such strategies.

Caring for people with learning disability using care management.

Current Government health policy is moving towards the delivery of services for clients with a learning disability through mainstream primary care services. At present there are difficulties in providing health services that meet the needs of clients. These include lack of resources (financial, physical and human), time and expertise. Yet clients with learning disabilities often have some of the most complex physical and mental health needs and they have a right to expect access to services that are responsive and sensitive to their requirements. In light of the current policy and stated difficulties, all service providers and stakeholders need to work together to review how services are provided and to negotiate shared resources. This article suggests adopting a care management approach, where clients are supported by different providers with a lead practitioner taking responsibility for assessment, planning and review in partnership with the client and his/her carers.