Discuss the importance of service user participation in the delivery of psychiatric nursing care.
Traditionally, people experiencing mental health problems were removed from society and placed in asylums across the country, indefinitely (Thornicroft and Tansella, 2002, pp. 84-90). Patients within the mental health system were expected to take a compliant role in the management of their care and leave the decision making to the professionals. In today’s society that is not the case. In this assignment the writer will begin by exploring the publication ‘Vision for Change’ while discussing the main theme of this publication which is ‘the importance of service user involvement and the importance of empowering the service user in the mental health system of Ireland’ (Ireland, Dept of Health & Children, 2006). To empower the service user requires the control of power to be transferred from the professionals to the now known “Service User”. The writer will discuss the effect of this change and the importance of this change within the mental health system. The Mental Health Act 2001 requested the closure of many asylums and the move towards a community based model of care. The deinstitutionalisation of many patients and relocation back into the community required changes in the way the psychiatric nurse and service user operate.
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Evidence has shown the importance of service user’s participation in research, education and in practice through out the mental health care system. The writer in this assignment will discuss the importance of service user participation in the delivery of psychiatric nursing care, focusing on the nursing assessment using a holistic approach.
Finally, the writer will discuss the importance of service user participation in the remaining stages of the nursing process; the nursing diagnosis, outcomes, planning, implementation and evaluation while exploring the need for a therapeutic relationship between service user and psychiatric nurse to complete the nursing process successfully.
With people experiencing mental health difficulties, who now reside in the community, it is vital that service users become involved in the development and delivery of mental health services, such as self-help services, drop-in centres, and in providing assistance with activities of daily living. The aim of this is to sensitise society to the need of integrating people with mental health difficulties back into community life.
As quoted in a Vision for Change;
“Service users must be at the centre of decision making at an individual level in terms of the services available to them, through to the strategic development of local services and national policy. To use a slogan of the disability rights movement: ‘nothing about us, without us’.
To reduce the stigma attached to people with mental health difficulties the term ‘patient’ was changed to service user, as most of the care they receive is provided in the community. The Mental Health Act, 2001 suggests ‘the term ‘patient’ is used to describe someone who is involuntarily admitted. Patient does not therefore refer to all individuals in an approved centre’. In the Vision for Change it states that ‘the correct way to describe someone with a mental health illness was to see the person before the illness, for example someone with anorexia nervosa was not to be described as ‘an anorexic’ rather than as a person with anorexia nervosa. Stereotyping in mental health is as damaging as any other stereotype (Ireland, Dept of Health & Children, 2006)’. People, who experience mental health difficulties, can be the experts through their own experience (Bee et al, 2008, pp. 442-447).
Psychiatric nurses remain the largest staff group involved in the provision of mental health care, (Bee et al, 2008, pp. 442-447). Therefore, to ensure the mental health care service abides by legislation, it is vital for psychiatric nurses to re-evaluate their role to ensure priority is given to including the service user. An Bord Altranais recommend that a holistic approach is adopted and it is listed as one of the requirements in nurse registration education programmes (An Bord Altranais, 2005). It is fundamental that the service user participates in the nursing assessment especially where the holistic model of assessment is used. The biopsychosocial model uses a holistic view, addressing the biological, psychological and social factors contributing to a person’s mental health problems. According to Boyd (2004, p.190) it proposes a person-centred treatment approach which addresses each of these elements through an integrated care plan agreed with service users and their carers and involves participation of the service user throughout the assessment. This assessment requires the service user to answer a series of questions, some being of intimate nature about themselves. This enables the assessor to obtain relevant information required in making a nursing diagnosis. To ensure accurate nursing diagnosis it is critical that the services user listens carefully to the questions asked and is completely honest when answering the questions. This process also requires the service user to be patient while the assessor records the data received. However, it is important to remember that an initial assessment can occur when a service user is first admitted into psychiatric care. According to Boyd (2004, p.194) the assessor must have empathy and an understanding of how difficult it is for a person to discuss intimate details of ones life’s to a complete stranger, even if it is in the person’s best interest.
Although the nursing assessment is the starting point of the nursing process, the writer feels that service user’s participation remains of equal importance throughout the nursing process. The freedom of information act 1997 requires that all services users can request access to any information stored about them. While, it is now a legal requirement for service users to be involved at all stages of the nursing process, the writer suggests that it is imperative that the service user is informed of the nursing diagnosis. This will empower the service user, by encouraging the service user to find relevant information regarding their diagnosis which can assist in them becoming experts of their own mental illness.
Following the diagnosis it is required by law that the psychiatric nurses discuss all details of the outcome with the service user. The psychiatric nurse needs to ensure that the service user’s values and beliefs are priority when planning the outcome. If any treatment is deemed necessary for the road to recovery, then it is compulsory that the service user is capable of understanding the effects of the treatment proposed, this requirement is stated Under the Mental Health Act, 2001:
“the service user must be capable of understanding the nature, purpose and likely effects of the proposed treatment and the consultant psychiatrist has given the patient adequate information in a form and language that the patient can understand, on the nature, purpose and likely effects of the proposed treatments (Section 56). Factors for consideration include the capacity to comprehend and decide, risks involved, patient’s wishes to be informed, the nature of the procedure and the effects of information on the service user.”
The service user must be informed of the benefits of taking the medication prescribed, for what duration the medication is to be taken and what side affects may occur when taking the prescribed medication. Forcing an unwilling inpatient to receive medication has been considered an unnecessarily coercive, traumatic, and even punitive assault on a person’s privacy. It has been stated that the patients’ refusal of medication is indicative of a gap between their experience and understanding of the medication and the intention of the prescribing physician. (Kaltiala-Heino et al, pp. 290-295) In today’s mental health care system, many service users receive treatment in the community; therefore, it is critical that services users listen to information regarding their prescribed medication while raising any concerns they may have.
Planning and the implementation stages of the nursing process are not possible without the involvement of the service user. Communication and agreement between the service user and the psychiatric nurse is necessary. Potential obstacles need to be pointed out, and methods of overcoming these obstacles, discussed. Potential risk areas for the service user needs to be discussed and a therapeutic risk assessment carried out by the psychiatric nurse to ensure the service user is not at risk or danger of harming themselves or others. Awareness of patients perceptions of their impaired quality of life gives psychiatric nurses important information for planning individually tailored interventions (Pitkänen, A. et al, 2008, pp. 1598-1606).
Finally, the evaluation stage evaluates client progress and reviews plans in accordance with evaluated data in consultation with the client. Evidence shows that the evaluation of a services users experience is of vital importance in shaping the future of service user’s outcomes within the mental health service. It also enables the psychiatric nurse to take the necessary steps required to ensure that the individual service user is satisfied with the service received. The Department of Mental Health, UK stated that the experience of service users, including those from black and minority ethnic groups, is a recognised national marker in the performance of the UK mental health services. In 2006, the UK National Service Framework (NSF) in line with the Mental Health Unit of the Regional Office for Europe carried out a systematic review of empirical service user views and expectations of UK-registered mental health nurses. Feedback from this review was both positive and negative, with service users holding mental health nurses in high regard. However; feedback also reveals that there was a strong need for nurses to be more effective in interpersonal communication and relationship building, whilst spending more time with the service user (Bee et al, 2008, pp. 442-447).
Throughout the nursing process it is necessary for a therapeutic relationship to exist between the service user and the psychiatric nurse to. Relationships are central in fostering and maintaining hope (Byrne et al 1994). Psychiatric nurses are required to have a genuine interest in services users, listening in a non judgemental way to what is being said. In a user-led study evidence has shown service users identified the importance of therapeutic relationships and how they inform patient experiences. Communication was highlighted by all participants as necessary. One participant in the survey quoted; “As soon as you come they can see that you are angry. Then someone will say, sit down, let’s talk about it, make a cup of tea.” Failure to establish a therapeutic relationship between the service user and the psychiatric nurse can result in negative patient experiences. Participants identified coercion as the main reason for failure to establish a therapeutic relationship (Gilburt, H. et al, 2008).
The writer in this assignment briefly exposed the treatment of patients within the mental health care prior to the introduction of the Mental Health Act 2001 and the publication of ‘Vision for Change’. Then, the writer discussed the major changes within the Mental Health Services as a result of this act and publication. The Mental Health Act 2001, focused on the closure of many asylums and a community based model of care to be adopted, however, both the Mental Health Act and the Vision for Change also focus on the importance of service user involvement and empowering the service user. The writer demonstrates how a new psychiatric and service user role was required to adapt to policy changes within the Mental Health Service and to ensure all parties were adapting to policy requirements that aims at service user involvement at all stages, thus; empowering the service user. The writer reports how the publication ‘Vision for Change’ also hoped at reducing stigma by aiming to involve services users in developing and delivering mental health services. The writer mentioned the importance of service user involvement in research, education and practice, while focusing on the practice area by exploring the nursing process, starting with the assessment. Evidence is clear that it is not possible for a psychiatric nurse, even with the necessary skills required to proceed with the nursing process without the participation of the service user at all stages. The writer concluded this assignment by exploring evidence which reveals that service users regard a therapeutic relationship and good communication between the service user and the psychiatric nurse of high importance.
An Bord Altranais (2005) ‘Requirements and Standards for Nurse Registration Education Programmes’. 3rd edn. Dublin: An Bord Altranais
Bee, P., Playle, J., Lovell, K., Barnes P., Gray, R., and Keeley P. (2008) ‘Service user views and expectations of UK-registered mental health nurses: A systematic review of empirical research’ International Journal of Nursing Studies, 45(3), pp. 442-457.
Boyd, M. (2004) Psychiatric nursing: contemporary practice. 3rd edn. Philadelphia: Lippincott Williams & Wilkins.
Gilburt, H., Rose, D., and Slade, M. (2008) ‘The importance of relationships in mental health care: A qualitative study of service users’ experiences of psychiatric hospital admission in the UK’ British Health Service Research, 8(92), [online] Available at: http://www.ncbi.nlm.nih.gov/sites/entrez (Accessed: 12 December 2009).
Government of Ireland (1997) Freedom of Information Act. Dublin: Stationery Office [online]. Available at http://www.foi.gov.ie/legislation (Accessed: 6 December 2009).
Government of Ireland (2001) Mental Health Act [online]. Available at http://www.mhcirl.ie/Mental_Health_Act_2001/Mental_Health_Act_2001.pdf (Accessed: 6 December 2009).
Hall, A., Wren, M. and Kirby, S. (2008) Care Planning in Mental Health: Promoting Recovery. 1st edn. Oxford: Blackwell Publishing.
Ireland, Department of Health & Children (2006) Vision for Change. Dublin: Department of Health and Children.
Kaltiala-Heino, R. (2003) ‘Involuntary medication in psychiatric inpatient treatment’ European Psychiatry, 18, pp.290-295.
Pitkänen , A. Hätönen, H., Kuosmanen, L., and Välimäki, M., (2008) ‘Patients’ descriptions of nursing interventions supporting quality of life in acute psychiatric wards: A qualitative study’ International Journal of Nursing Studies, 45(11), pp. 1598-1606.
Repper, J. and Perkins, R. M. (2003) Social Inclusion and Recovery: A Model for Mental Health Practice. 1st edn. London: Bailliere Tidall.
Thornicroft, G. and Tansella, M. (2002) ‘Balancing community-based and hospital-based mental health care’ World Psychiatry, 1(2), pp. 84-90.
United Kingdom, Department of Health, (1999) National Service Framework (NSF) for Mental Health [online]. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4077209.pdf (Accessed: 9 December 2009).
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