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Abstract: Background: Trials of complex interventions should be preceded by in-depth piloting of the treatment in order to ensure clear definition of critical components and establish feasibility and acceptability. Objectives: This study aimed to elicit views of extending behavioural activation, an evidence-based treatment for depression, to the negative symptoms observed in psychosis from the perspectives of carers of people with mental health problems and mental health professionals. Design: Qualitative study. Setting: School of Nursing, Midwifery and Social Work and carer support organisation, North West of England, United Kingdom. Participants: Fifteen participants were recruited from a local carer support group. Nineteen mental health professionals were recruited from post-registration university based programmes. Methods: We used focus groups and semi-structured interviews. Thematic analysis using a constant comparative approach was employed to capture key concepts and themes. Results: There was support for behavioural activation for negative symptoms in psychosis from some mental health workers and many of the carers; however both groups identified barriers to its implementation. Professionals highlighted internal factors, the difficulty in engaging people with negative symptoms in psychosocial treatments and services more broadly while carers identified a number of external, practical barriers. For those who saw some utility in the treatment approach, the benefit of expanding the treatment to include community based sessions as well as formal behavioural activation meetings were recognised. However, a number of mental health professionals remained sceptical as to its potential to reduce negative symptoms. Professional and carer views generally concurred in relation to family involvement, indicating that restricted engagement could be helpful, but that further participation might actually be counterproductive. Conclusions: Acceptability for many carers and some professionals was evident and support further evaluation of behavioural activation for negative symptoms. Significant issues to be addressed include the balance of formal talking based sessions and community based sessions to support activation for people with negative symptoms and mental health professional pessimism in relation to this symptom cluster. The current study supports the phased development and careful piloting of complex healthcare interventions before progression to large scale evaluation. [Copyright &y& Elsevier]

Abstract: Background: Antipsychotic treatment is important in reducing symptomatology and relapse in schizophrenia. Community mental health professionals (CMHPs) have a significant role in this treatment; however, evidence suggests that many are ineffective in medication management. Objectives: To develop and evaluate a medication management training programme whose aims are to increase the effectiveness of pharmacological treatment and increase services users’ involvement in treatment decisions. Participants: Twenty-eight pairs of CMHPs were recruited from mental health Trusts in England. For each practitioner an average of 3.4 service users were randomly selected for their ‘study caseload’. Design: A pragmatic cluster randomised trial assessed the service users of CMHPs allocated to medication management training or waiting list controls. Methods: All practitioner participants were taught to use a variety of assessment measures and undertook baseline assessments with their service users. The experimental practitioners then attended the training programme. At the 9-month endpoint the service users were re-assessed. Results: After the outcome data was adjusted for clustering the trained practitioners made significant improvements in global psychopathology and service user involvement in treatment when compared to controls at 9 months. Conclusions: Training CMHPs in medication management has a positive impact on clinical outcomes and service user involvement in treatment. [Copyright &y& Elsevier]

Abstract: Objectives: To review national (UK) literature in order to (i) examine service user and carer views of UK-registered mental health nurses; (ii) identify the diversity of populations from which these views have been collected; (iii) assess the methodological rigour of the current knowledge base and (iv) evaluate the extent to which service users and carers have been involved in the development and execution of this work. This paper reports only on service users’ views. Design: Systematic review. Data sources: Electronic and evidence-based databases, reference checking and hand searching of key academic journals, national policy and user/carer organisational websites. Review methods: Two reviewers independently undertook study eligibility judgements and data extraction. Eligible studies were sub-classified according to service setting (inpatient/residential, community/non-residential or mixed/unspecified). Each study was assessed against key quality criteria. Data were synthesised in a narrative format. Results: One hundred and thirty two studies were included in the review. The majority were small-scale academic studies biased towards white, adult service users. Few studies provided evidence of user collaboration. Service users regard mental health nursing as a multi-faceted role delivering practical and social support alongside more formal psychological therapies. Service users report inadequate information provision, poor inter-professional communication and a lack of opportunities for collaborative care. Service users perceive inpatient mental health nurses as particularly inaccessible. Conclusions: UK-registered mental health nurses should be equipped with both therapeutic clinical skills and generic skills associated with relationship building, engagement and communication. Future research should be conducted in collaboration with service users and include clear and effective mechanisms for the dissemination and implementation of research findings. In particular, the views of children and adolescents, the elderly and black and minority ethnic groups, currently under-represented in research, should be examined. [Copyright &y& Elsevier]

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships. We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings. Systematic literature review. The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted. Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment. Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality. The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients. [ABSTRACT FROM AUTHOR]

Background De-escalation techniques are recommended to manage violence and aggression in mental health settings yet restrictive practices continue to be frequently used. Barriers and enablers to the implementation and effectiveness of de-escalation techniques in practice are not well understood. Objectives To obtain staff descriptions of de-escalation techniques currently used in mental health settings and explore factors perceived to influence their implementation and effectiveness. Design Qualitative, semi-structured interviews and Framework Analysis. Settings Five in-patient wards including three male psychiatric intensive care units, one female acute ward and one male acute ward in three UK Mental Health NHS Trusts. Participants 20 ward-based clinical staff. Methods Individual semi-structured interviews were digitally recorded, transcribed verbatim and analysed using a qualitative data analysis software package. Results Participants described 14 techniques used in response to escalated aggression applied on a continuum between support and control. Techniques along the support-control continuum could be classified in three groups: ‘support’ ( e.g. problem-solving, distraction, reassurance) ‘non-physical control’ ( e.g. reprimands, deterrents, instruction) and ‘physical control’ ( e.g. physical restraint and seclusion). Charting the reasoning staff provided for technique selection against the described behavioural outcome enabled a preliminary understanding of staff, patient and environmental influences on de-escalation success or failure. Importantly, the more coercive ‘non-physical control’ techniques are currently conceptualised by staff as a feature of de-escalation techniques, yet, there was evidence of a link between these and increased aggression/use of restrictive practices. Risk was not a consistent factor in decisions to adopt more controlling techniques. Moral judgements regarding the function of the aggression; trial-and-error; ingrained local custom (especially around instruction to low stimulus areas); knowledge of the patient; time-efficiency and staff anxiety had a key role in escalating intervention. Conclusion This paper provides a new model for understanding staff intervention in response to escalated aggression, a continuum between support and control. It further provides a preliminary explanatory framework for understanding the relationship between patient behaviour, staff response and environmental influences on de-escalation success and failure. This framework reveals potentially important behaviour change targets for interventions seeking to reduce violence and use of restrictive practices through enhanced de-escalation techniques. [ABSTRACT FROM AUTHOR]

Background Involving users/carers in mental health care-planning is central to international policy initiatives yet users frequently report feeling excluded from the care planning process. Rigorous explorations of mental health professionals’ experiences of care planning are lacking, limiting our understanding of this important translational gap. Objectives To explore professional perceptions of delivering collaborative mental health care-planning and involving service users and carers in their care. Design Qualitative interviews and focus groups with data combined and subjected to framework analysis. Setting UK secondary care mental health services. Participants 51 multi-disciplinary professionals involved in care planning and recruited via study advertisements. Results Emergent themes identified care-planning as a meaningful platform for user/carer involvement but revealed philosophical tensions between user involvement and professional accountability. Professionals emphasised their individual, relational skills as a core facilitator of involvement, highlighting some important deficiencies in conventional staff training programmes. Conclusions Although internationally accepted on philosophical grounds, user-involved care-planning is poorly defined and lacks effective implementation support. Its full realisation demands greater recognition of both the historical and contemporary contexts in which statutory mental healthcare occurs. [ABSTRACT FROM AUTHOR]

Abstract: Background: Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild–moderate psychological distress. Objective: This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care. Design: A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis. Setting: A large teaching maternity hospital in North West England. Participants: Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care. Results: Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements. Conclusions: Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have. [Copyright &y& Elsevier]