Quality of life among people living with mental illness and predictors in Africa: a systematic review and meta-analysis.

INTRODUCTION: Quality of life (QoL) of patients with mental illness has been examined internationally but to a lesser extent in developing countries, including countries in Africa. Improving QoL is vital to reducing disability among people with mental illness. Therefore, this systematic review and meta-analysis aimed to assess the prevalence of QoL and associated factors among people living with mental illness in Africa. METHODS: Using the PICOT approach, Scopus, MEDLINE, PsycINFO, CINAHL, Embase, the Web of Science, and Google Scholar were searched. A structured search was undertaken, comprising terms associated with mental health, mental illness, QoL, and a list of all African countries. The Joanna Briggs Institute Quality Appraisal Checklist is used to evaluate research quality. Subgroup analysis with Country, domains of QoL, and diagnosis was tested using a random-effect model, and bias was assessed using a funnel plot and an inspection of Egger's regression test. A p value, OR, and 95% CI were used to demonstrate an association. RESULTS: The pooled prevalence of poor QoL was 45.93% (36.04%, 55.83%), I2 = 98.6%, p < 0.001). Subgroup analysis showed that Ethiopia (48.09%; 95% CI = 33.73, 62.44), Egypt (43.51%; 95% CI = 21.84, 65.18), and Nigeria (43.49%; 95% CI = 12.25, 74.74) had the highest mean poor QoL prevalence of the countries. The pooled prevalence of poor QoL by diagnosis was as follows: bipolar disorder (69.63%; 95% CI = 47.48, 91.77), Schizophrenia (48.53%; 95% CI = 29.97, 67.11), group of mental illnesses (40.32%; 95% CI = 23.98, 56.66), and depressive disorders (38.90%; 95% CI = 22.98, 54.81). Being illiterate (3.63; 95% CI = 2.35, 4.91), having a comorbid medical illness (4.7; 95% CI = 2.75, 6.66), having a low monthly income (3.62; 95% CI = 1.96, 5.27), having positive symptoms (0.32; 95% CI = 0.19, 0.55), and having negative symptoms (0.26; 95% CI = 0.16, 0.43) were predictors of QoL. Thus, some factors are significantly associated with pooled effect estimates of QoL. CONCLUSIONS: The current systematic review and meta-analysis showed that almost half of patients with mental illness had poor QoL. Being illiterate, having a comorbid medical condition, having a low monthly income, having positive symptoms, and having negative symptoms of mental illness were independent predictors of poor QoL. This systematic review and meta-analysis emphasize that poor QoL of people with mental illness in Africa needs attention to reduce its negative consequences.

Internalised stigma among people with mental illness in Africa, pooled effect estimates and subgroup analysis on each domain: systematic review and meta-analysis.

BACKGROUND: Internalisation of stigma occurs when people with a stigmatised attribute, such as a mental illness, supress negative but accepted societal attitudes. However, as far as is known, there is no comprehensive picture of the prevalence of and factors associated with, internalised stigma among people living with mental illness in Africa. This systematic review and meta-analysis provide new knowledge by examining the evidence on the prevalence of internalised stigma and associated factors among people living with mental illness in Africa. METHODS: Using the population, intervention, comparison, outcome, and type of study (PICOT) approach, PubMed, Scopus, MEDLINE, PsycINFO, CINAHL, ScienceDirect, and Google Scholar were searched using a structured search comprising terms associated with mental health, mental illness, internalised stigma, and a list of all African countries. To evaluate paper quality, the Joanna Briggs Institute Quality Appraisal Checklist was used. Subgroup analysis with country and diagnosis was tested using a random-effect model, and bias was checked using a funnel plot and an inspection of Egger's regression test. A p-value, OR and 95% CI was used to demonstrate an association. RESULTS: The pooled prevalence of internalised stigma was 29.05% (25.42,32.68: I2 = 59.0%, p ≤ 0.001). In the subgroup analysis by country, Ethiopia had the highest prevalence of internalised stigma at 31.80(27.76,35.84: I2 = 25.6%, p ≤ 0.208), followed by Egypt at 31.26(13.15,49.36: I2 = 81.6%, p ≤ 0.02), and Nigeria at 24.31(17.94,30.67: I2 = 62.8%, p ≤ 0.02). Based on domains of internalised stigma, pooled prevalence was stigma resistance: 37.07%, alienation: 35.85%, experience of discrimination: 31.61%, social withdrawal: 30.81% and stereotype: 26.10%. Experiencing psychotic symptoms (1.42(0.45,2.38)), single marital status (2.78(1.49,4.06)), suicidal ideation (2.32(1.14,3.49)), drug nonadherence (1.5(-0.84,4.00)), poor social support (6.69(3.53,9.85)), being unemployed (2.68(1.71,3.65)), and being unable to read and write (3.56(2.26,4.85)) were identified as risk factors for internalised stigma. CONCLUSIONS: Internalised stigma is common among people suffering from mental illnesses in Africa. This review determined that 29% of the sample population had elevated internalised stigma scores, and there were variations by country. People experiencing mental illness who have a single marital status, suicidal behaviours, poor social support, unemployed and have poor literacy levels were at a higher risk of internalised stigma. The finding points to populations that require support to address internalised stigma and improve the mental health outcomes.

Comparisons on factors affecting residents fulfilling self-determination in ethno-specific and mainstream nursing homes: a qualitative study.

BACKGROUND: Studies revealed that supporting residents fulfilling self-determination is positively associated with their health, wellbeing and quality of life. Cross-cultural care poses significant challenges for nursing home residents to fulfil their self-determination in control of own care and maintaining meaningful connections with others. The aim of the study was to compare factors affecting residents fulfilling self-determination in ethno-specific and mainstream nursing homes. METHODS: A qualitative descriptive approach was applied to the study. Culturally competent care and person-centred care were employed as guiding frameworks. Individual interviews or a focus group with residents and family members were conducted to collect data. RESULTS: In total, 29 participants participated in the study. Three main themes were identified: communicating needs and preferences; mastering own care; and maintaining meaningful relationships. Each theme includes sub-themes that detail similarities and differences of factors affecting residents fulfilling self-determination in the two type nursing homes. Findings indicate that residents from both types of nursing homes experienced challenges to communicate their care needs and preferences in daily care activities. Moreover, residents or their representatives from both types of nursing homes demonstrated motivation and competence to master residents' care based on their individual preferences, but also perceived that their motivation was not always supported by staff or the nursing home environment. Residents' competence in mastering their care activities in ethno-specific nursing homes was based on the condition that they were given opportunities to use a language of choice in communication and staff and the nursing home demonstrated culturally competent care for them. In addition, ethno-specific nursing homes showed more recourse to support residents to maintain meaningful relationships with peers and others. CONCLUSIONS: Culturally competent care created by staff, nursing homes and the aged care system is a basic condition for residents from ethnic minority groups to fulfil self-determination. In addition, person-centred care approach enables residents to optimise self-determination.

Staff perceived challenges and facilitators in supporting resident self-determination in ethno-specific and mainstream nursing homes.

AIMS AND OBJECTIVES: To explore and compare staff perceived challenges and facilitators in supporting resident self-determination in ethno-specific and mainstream nursing homes. BACKGROUND: Staff and residents in ethno-specific and mainstream nursing homes in most developed countries have shown increased cultural and linguistic diversity. This socio-demographic change poses significant challenges for staff to support resident self-determination of their own care. In-depth understanding of those challenges in the two types of nursing homes is much needed to inform practice in nurse-led nursing home care settings. METHOD: A qualitative description approach with thematic analysis was used in the study. Data were collected through five focus groups with 29 various direct care workers from two ethno-specific nursing homes and a mainstream nursing home in Australia between March-September 2020. The study report followed the COREQ checklist. RESULTS: Four themes were identified from focus group data. First, participants perceived communication challenges in identifying residents' preferences, especially in ethno-specific nursing homes. Second, team efforts that included residents and their family members were highly valued as a way to meet residents' preferences. Third, participants described various levels of staff engagement in residents' care planning. In addition, staff in ethno-specific nursing homes possessed richer resources to maintain meaningful relationships for residents compared with their counterparts in the mainstream nursing home. CONCLUSIONS: Staff in ethno-specific nursing homes experience more challenges in supporting resident self-determination but have richer resources to develop culturally safe and culturally competent care compared with their counterparts in the mainstream nursing home. RELEVANCE TO CLINICAL PRACTICE: Findings provide new insights into challenges and practical solutions in supporting residents to self-determine their own care in cross-cultural aged care. PATIENT OR PUBLIC CONTRIBUTION: This study was co-designed with three aged care organisations who funded the study. Staff employed by these organisations participated in the study.

Community treatment orders and care planning: How is engagement and decision-making enacted?

BACKGROUND: In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery-focussed. Key components in the care planning process include engagement and decision-making about a person's support needs and care options, with trust being an essential component of care planning relationships. OBJECTIVE: This study examines how these components were enacted during service care contacts for individuals on community treatment orders. METHODS: The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day-to-day care interactions. RESULTS: Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of 'knowing', with consumers assumed to have less knowledge than clinicians. CONCLUSIONS: Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision-making. PATIENT OR PUBLIC CONTRIBUTION: This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.

Chemical restraint: A qualitative synthesis review of adult service user and staff experiences in mental health settings.

With an imperative to reduce or eliminate the use of coercive practices in mental health care it is important to understand the experience of service users and staff. This review aimed to synthesize qualitative studies, published between 1996 and 2020, reporting on mental health service users' and staff's experiences of chemical restraint. The databases PsycINFO, CINAHL, MEDLINE, Embase, Emcare, Web of Science, and Scopus were searched. Three analytic themes were identified from 17 included articles, synthesizing the experiences of service users and staff. These were "Unjustified versusjustified," "Violence versus necessity," and "Reflecting back: Positives and negatives." Service users viewed chemical restraint as an unjustified response to "behaviors of concern" and experienced it as a violent act with negative outcomes, although some saw it as necessary in retrospect and preferred it to other forms of coercion. Staff generally viewed it as a justified response to "behaviors of concern" and experienced it as appropriate within the constraints of staff numbers and limited alternatives. These findings identify nuances not apparent in the literature, which has generally conflated all forms of coercive practices.

The impact of workplace culture on the accountability of mental health nurses to involve consumers in care planning: A focused ethnography.

Recovery-oriented mental health practice guidelines recommend regular consumer involvement in care plans, yet in many acute settings, these are not routinely created thereby compromising accountability. This study explored the impact of workplace culture on the capacity of mental health nurses to involve consumers in care planning and consequently to work accountably. A focused ethnography was undertaken in one Australian inpatient unit involving mental health nurses and other health professionals. Data were derived from in-depth semistructured interviews with 12 nurses and 6 months of nonparticipant observation of multidisciplinary meetings and clinical handovers. Workplace culture had an impact on mental health nurses' accountability practices. A culture that prioritized reduction in length of stay resulted in less recovery-oriented care. Health professionals who paid more attention to crisis and risk management resulted in fewer opportunities for consumer-involved care planning.

The barriers to evidence-based nursing implementation in mainland China: A qualitative content analysis.

It has been widely recognized that healthcare practices should be based on up-to-date high-quality evidence; however, the implementation of evidence has been a slow process in nursing practice. It is crucial for clinical practitioners to be aware of the barriers to implementing evidence-based nursing. The aim of this study was to describe participants' experiences and thoughts on barriers to implementing evidence-based nursing in mainland China. Forty-five participants came from 45 evidence-based nursing implementation projects carried out in 16 hospitals in mainland China. Data were collected through observation and semi-structured interviews, after which qualitative content analysis was undertaken. Then, the five themes and subthemes were extracted from the data. The five themes were evidence-based, nurse-related, patient-related, setting barriers, and lack of support. In this study, a variety of barriers influencing evidence implementation in the Chinese nursing context were identified and further explored from the perspective of clarifying misunderstandings about evidence-based nursing, the profound influence of Chinese culture on patients' preferences and attitudes, and the lack of professional knowledge of nurses.

Role of security guards in Code Black events in medical and surgical settings: A retrospective chart audit.

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

Recovery college as a transition space in the journey towards recovery: An Australian qualitative study.

Recovery colleges are formal learning programs that aim to support people with a lived experience of mental illness. In this study, we aimed to explore the experiences of participants in a pilot recovery college that opened in Adelaide, South Australia, in 2016. A qualitative exploratory study was conducted involving interviews with learners (n = 8) and focus groups with lived experience facilitators (course facilitators with a lived experience of mental illness, n = 5), Clinician facilitators (mental health service staff facilitators, n = 4), and care coordinators (staff providing case management support, n = 5). Three main themes (hope, identity, and the recovery college as a transition space) and two subthemes (recovery college experience and outcomes) were identified. The results showed that the recovery college provided a transition space for shifting learners' identities from patient to student, facilitated by the experiences and outcomes of the recovery college, providing hope for the future. This study highlights the importance of providing mentally healthy and non-stigmatizing learning environments to promote and cement recovery for people with a lived experience of mental illness.

How do clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation?

AIMS AND OBJECTIVES: To examine how clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation. BACKGROUND: Family presence during resuscitation has important benefits for family and is supported by professional bodies and the public. Yet, many clinicians restrict family access to patients during resuscitation, and rationales for decision-making are unclear. DESIGN: Secondary analysis of an existing qualitative data set using deductive category application of content analysis. METHODS: We analysed 20 interview transcripts from 15 registered nurses, two doctors and three paramedics who had experienced family presence during resuscitation in an Australian hospital. The transcripts were analysed for incidents of beneficent decision-making when allowing or denying family presence during resuscitation. RESULTS: Decision-making around family presence during resuscitation occurred in time poor environments and in the absence of local institutional guidelines. Clinicians appeared to be motivated by doing "what's best" for patients and families when allowing or denying family presence during resuscitation. However, their individual interpretations of "what's best" was subjective and did not always coincide with family preferences or with current evidence that promotes family presence during resuscitation as beneficial. CONCLUSIONS: The decision to allow or deny family presence during resuscitation is complex, and often impacted by personal preferences and beliefs, setting norms and tensions between clinicians and consumers. As a result, many families are missing the chance to be with their loved ones at the end of life. The introduction of institutional guidelines and policies would help to establish what safe and effective practice consists of, reduce value-laden decision-making and guide beneficent decision-making. RELEVANCE TO CLINICAL PRACTICE: These findings highlight current deficits in decision-making around FPDR and could prompt the introduction of clinical guidelines and policies and in turn promote the equitable provision of safe, effective family-centred care during resuscitation events.

The benefits of sensory modulation on levels of distress for consumers in a mental health emergency setting.

OBJECTIVES: This paper reports a pilot study exploring the benefits of offering sensory modulation within a mental health emergency setting for consumers experiencing distress during a psychiatric presentation. METHODS: Seventy-four consumers with a mental health presentation reported on their sensory modulation use experiences during their stay in a South Australian tertiary teaching hospital emergency department. An evaluation form was used to document use of items, self-reported distress pre and post sensory modulation use, and other consumer experiences. RESULTS: Consumers used between one and six sensory items for a median duration of 45 min. There was a statistically significant reduction ( t(73) = 15.83, p < .001) in self-reported distress post sensory modulation use, and consumers also reported that use was helpful, distracting, calming and assisted in managing negative emotions and thoughts. CONCLUSIONS: The results demonstrate the potential value of sensory-based interventions in reducing behavioural and emotional dysregulation in an emergency setting whilst also promoting consumer self-management strategies.

Carers' experiences of accessing and navigating mental health care for older people in a rural area in Australia.

OBJECTIVES: Mental health care for older people is primarily delivered in the community and is largely dependent on informal carers. Mental health policy encourages partnerships between carers and service providers to facilitate service access, coordination and positive experience of care. However, carers often lack information and support from services, with the potential for carer burden, and negative impacts on their own health and capacity to fulfil caring tasks. This paper explores rural carers' experiences of accessing care from a range of services for older people with mental health problems. METHOD: The Pathways Interview Schedule was used to facilitate 9 in-depth care journey interviews with 11 carers of older people with a mental health problem. Interviews explored their journeys to and through mental health, aged care, primary care and social care services. Framework analysis was used to explore carers' experiences and perceptions of care with a focus on access enablers and barriers. RESULTS: Carers had a significant role in navigating services and operationalising care for their relative. Enablers to accessing care included carer knowledge and workers actively involving carers in planning. Barriers included carer mental health literacy, consumer and carer readiness for services, and worker misinterpretation of confidentiality and privacy laws. CONCLUSION: Carers should be considered key partners in mental health care planning that crosses service sectors. For this to occur, changes are required at the worker level, including increased communication between mental health workers and carers, and the service level, involving training for staff in interpreting confidentiality and privacy policy.

Care planning for consumers on community treatment orders: an integrative literature review.

BACKGROUND: Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs. METHODS: An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management. RESULTS: Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions. CONCLUSIONS: Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.

Factors influencing decision-making around family presence during resuscitation: a grounded theory study.

AIM: The aim of this study was to examine factors impacting family presence during resuscitation practices in the acute care setting. BACKGROUND: Family presence during resuscitation was introduced in the 1980s, so family members/significant others could be with their loved ones during life-threatening events. Evidence demonstrates important benefits; yet despite growing support from the public and endorsement from professional groups, family presence is practiced inconsistently and rationales for poor uptake are unclear. DESIGN: Constructivist grounded theory design. METHODS: Twenty-five health professionals, family members and patients informed the study. In-depth interviews were undertaken between October 2013-November 2014 to interpret and explain their meanings and actions when deciding whether to practice or participate in FPDR. FINDINGS: The Social Construction of Conditional Permission explains the social processes at work when deciding to adopt or reject family presence during resuscitation. These processes included claiming ownership, prioritizing preferences and rights, assessing suitability, setting boundaries and protecting others/self. In the absence of formal policies, decision-making was influenced primarily by peoples' values, preferences and pre-existing expectations around societal roles and associated status between health professionals and consumers. As a result, practices were sporadic, inconsistent and often paternalistic rather than collaborative. CONCLUSION: An increased awareness of the important benefits of family presence and the implementation of clinical protocols are recommended as an important starting point to address current variations and inconsistencies in practice. These measures would ensure future practice is guided by evidence and standards for health consumer safety and welfare rather than personal values and preferences of the individuals 'in charge' of permissions.

Risk assessment and absconding: perceptions, understandings and responses of mental health nurses.

AIMS AND OBJECTIVES: This paper reports mental health nurses' perspectives of absconding. The aims of the study were to explore nurses' perceptions of risk assessment and management practices regarding absconding from acute inpatient psychiatric settings, and their affective responses when patients absconded. BACKGROUND: Nurses are directly involved in managing the risk of patients leaving hospital while acutely unwell, as well as dealing with the implications of an absconding event. However, despite their key role, few studies have explored nurses' perceptions of absconding. DESIGN: An interpretive inquiry was undertaken using a systematic thematic approach. METHODS: Mental health nurses (n = 11) from three acute inpatient mental health units in Australia took part in semi-structured interviews, with a focus on the nurses' experiences of working with patients who had absconded. Data were analysed using systematic thematic coding procedures. RESULTS: Nurses' assessment of a patient's risk of absconding involved the use of clinical judgement, focusing on markers of absconding including the patient's history and clinical presentation. The acuity of the perceived risk determined the type of risk management strategy implemented, which could include support, observation and/or the use of containment procedures. Nurses responded with a myriad of affective reactions when patients absconded depending on their assessment of the patient's risk. CONCLUSIONS: Support and debriefing is required for mental health nurses following an absconding event. Additional research is vital to identify alternative absconding assessment and management strategies to ensure the best possible outcome for patients and nurses. RELEVANCE TO CLINICAL PRACTICE: Mental health nurses play a central role in risk assessment and management for absconding, with fear of repercussions a significant consequence for them. This research highlights the importance of both clinical judgment and standardised instruments in assessing absconding risk. Further research is needed to identify alternative evidence-based absconding management strategies to support nursing practice.

Child and adolescent mental health nursing seen through a social constructionist lens.

AIM: To discuss the theoretical framework of social constructivism and justify it s appropriateness for and compatibility with an interpretive approach to child adolescent mental health (CAMH) nursing research. BACKGROUND: Recent changes to national nursing legislation in Australia have resulted in the removal of the separate register with regulatory authorities that existed for the specialty of mental health nursing. Aspects of mental health nursing age are not easily defined, with some being tacit. CAMH nursing is a sub-specialty area of mental health in which the role and function of these nurses is also not overtly understood. DATA SOURCE: An interpretive research study was designed to develop a deeper understanding of the role and work of CAMH nurses when working in an inpatient setting. REVEW METHODS: An interpretive enquiry methodology was used fro the study, with three sequential stages of data collection: document analysis, focus group interviews and semi-structured individual interviews. DISCUSSION: Social constructionism was the chosen theoretical framework for this study as it provided a useful lens for interpreting and understanding the work of the CAMH nurse. CONCLUSION: The social constructionist lens was simpatico with mental health nursing, as they both involved making meaning of or assessing information and understanding of social processes and interactions. IMPLICATIONS FOR REEARCH/PRACTICE: A useful lens for further research into mental health nursing practice.

Attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient units.

BACKGROUND: In psychiatry, most of the focus on patient aggression has been in adolescent and adult inpatient settings. This behaviour is also common in elderly people with mental illness, but little research has been conducted into this problem in old age psychiatry settings. The attitudes of clinical staff toward aggression may affect the way they manage this behaviour. The purpose of this study was to examine the attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient settings. METHODS: A convenience sample of clinical staff were recruited from three locked acute old age psychiatry inpatient units in Melbourne, Australia. They completed the Management of Aggression and Violence Scale, which assessed the causes and managment of aggression in psychiatric settings. RESULTS: Eighty-five staff completed the questionnaire, comprising registered nurses (61.1%, n = 52), enrolled nurses (27.1%, n = 23) and medical and allied health staff (11.8%, n = 10). A range of causative factors contributed to aggression. The respondents had a tendency to disagree that factors directly related to the patient contributed to this behaviour. They agreed patients were aggressive because of the environment they were in, other people contributed to them becoming aggressive, and patients from certain cultural groups were prone to these behaviours. However, there were mixed views about whether patient aggression could be prevented, and this type of behaviour took place because staff did not listen to patients. There was agreement medication was a valuable approach for the management of aggression, negotiation could be used more effectively in such challenging behaviour, and seclusion and physical restraint were sometimes used more than necessary. However, there was disagreement about whether the practice of secluding patients should be discontinued. CONCLUSIONS: Aggression in acute old age psychiatry inpatient units occurs occasionally and is problematic. A range of causative factors contribute to the onset of this behaviour. Attitudes toward the management of aggression are complex and somewhat contradictory and can affect the way staff manage this behaviour; therefore, wide-ranging initiatives are needed to prevent and deal with this type of challenging behaviour.

Service provision for older people with mental health problems in a rural area of Australia.

OBJECTIVES: Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia. METHOD: Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data. RESULTS: Two main themes were identified: 'Recognising the Problem' and 'Service Availability and Access'. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region. CONCLUSION: This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people.