The Importance of Nurses Training - Literature review Example

Lecturer: A critical evaluation of the literature exploring nursing management of patients with psychosis who engage with substance misuse Abstract This critical evaluation sought to look into nursing management of patients with psychosis who engage in substance abuse upon admission to the mental health institution in the UK. The major themes of discussions from the literature reviewed included: the relationship between substance abuse and individuals with mental illness such as psychosis – this could also be related to the relationship between dual diagnosis; the importance of nurse’s training as well as knowledge of screening and assessment of dual diagnosis in patients; the importance of understanding and working with service users experiences. The key findings from the literature reviewed revealed that: dual diagnosis may affect 30% to 70% of patients who visit mental illness institutions. Secondly, patients with dual diagnosis may encounter major social, physical as well as psychological problems in their day to day lives. Thirdly, nurses have improved their knowledge in screening as well as patient assessment. Fourth, patients with mental illness were noted to have mild to severe substance abuse (illicit drugs, alcohol and smoking) related challenges before they were actually admitted to the mental health institution. This was due to the fact that these drugs would help them deal with their illness better. Lastly, comorbidity and/ or co-occurring diseases or disorders was noted in these patients. The strengths and the limitations of the methodologies used were related to the design of the study, the sampling methods used and the data collection techniques. As such, the literature reviewed propagated for the need of further research into nursing management and training that would help to better cope with dual diagnosis; improved screening and assessment of mental illness patients; better access to treatment as well as treatment options and services for patients with mental illness and the need to understand and work with different service users experiences. Key words: “Nursing management of patients with psychosis”; “comorbidity”; “Psychosis”; “Acute intoxication of patients with psychosis”; “drugs that propagate psychosis”. Table of contents Abstract 1 Table of contents 2 Introduction 4 Rationale (Underlying principles) 5 Search study 6 Literature Review – Discussion of the themes 8 Relationship between substance abuse and individuals with mental illness such as psychosis 8 The importance of nurse’s training as well as knowledge of screening and assessment of dual diagnosis in patients 9 The importance of understanding and working with service users experiences 12 Bibliography 13 Introduction Psychosis can be termed as a mental illness that causes an individual to become distant from reality (RCPsych, 2013). This may include the patient having false beliefs about real world situations (commonly referred to as delusions) or a state where the individual sees or hears things which in actual place are not existent (commonly referred to as hallucinations) (NHS, 2012; Mind, 2013). In addition to that, some individuals could have periods of confusion and/or disturbed thoughts as well as the lack of self awareness and self insight (Mind Health Care, 2014; NHS UK, 2012). Psychosis is a mental disorder whose causes are highly attributed to three (3) reasons. These include: psychosis that is caused by substance abuse (illicit drugs, alcohol and smoking) (Casadio, et al., 2011; Di Forti et al., 2009; Harley, et al., 2010; Frisher, et al., 2009; Frisher, et al., 2013; NHS UK, 2012; Candi.NHS UK, N.d); psychosis that is caused by mental challenges (psychological psychosis); psychosis that is caused by general conditions (NHS UK, 2012). Based on that, psychosis has a number of variants (Candi.NHS UK, N.d). Some of them include: Schizophrenia - This disorder is related to psychosis (DoH, 2011) in the form that the individual always exhibits one or two symptoms that are related to psychosis for a period of six (6) months. Moreover, the individual usually looses their ability to functions optimally since their mental capabilities are always “challenged” (Candi.NHS UK, N.d). With regard to this disorder, the symptoms usually vary between patients as some may exhibit worse instances of the disorder when compared to others. Schizophreniform disorder - This disorder is related to schizophrenia and part of the psychosis disorders (Douglas, et al., 2009; Kelleher and Cannon, 2011; Owen et al., 2011; Welham et al., 2009). The only difference is that the symptoms displayed by the individual last for a period less than six (6) months. Drug induced psychosis - This form of psychosis is related to drugs such as: cannabis and alcohol (Crome and Chambers, 2009; Healey et al., 2009; Berry et al., 2013; Kolliakou et al., 2011; NICE, 2011; Kelly et al., 2011; Sterling et al., 2011). Based on that, this literature review will focus on specific literature and research information and evidence that are highly related to the following themes: the relationship between substance abuse and individuals with mental illness such as psychosis – this could also be related to the relationship between dual diagnosis; the importance of nurse’s training as well as knowledge of screening and assessment of dual diagnosis in patients; the importance of understanding and working with service users experiences. The search strategy that shall be implemented in this critical appraisal shall also be outlined as well as the sources of the search strategies. Based on the studies being researched and analysed, their methodologies strengths and limitations shall also be highlighted. Finally, the key findings shall also be discussed and evaluated as per the themes discussed. Rationale (Underlying principles) In a research study that was conducted in England in 2010, it was revealed that there was always a new diagnosed case of psychosis in every 2000 people. In addition to that, another study revealed that at least 1 person in every 100 people had had a minor case of psychosis in their lives. Moreover, it was noted that the first cases of psychosis in these patients was when they were aged 15 years to their adulthood. This research study in England also went ahead to reveal that psychosis in children aged below 15 years was rare – with numbers approximately one child per 500 children (NHS UK, 2012). With regard to substance abuse, it was also noted that a majority of psychotic patients always arrive at the psychiatric mental institution while they are under the influence of drugs. According to NICE (2011), 40% of the patients who had been previously screened and assessed with psychosis were also determined to have engaged in substance abuse at one point in their lives. The same study also revealed that there were psychotic patients who were coexisting between substance abuse and their condition. This was stated to have a fatal effect of the risk of enduring relapses as well as hospitalization as compared to patients who were first time users of substance abuse. There are a number of reasons as to why a patient in the psychiatric institution would indulge in drugs. One of them would be an easy way out of dealing with their disorder due to its adverse symptoms (NHS UK, 2012). Moreover, patients who have coexisting substance misuse tend to perform worse than patients who have less frequencies of coexisting substance misuse since the drugs could be aggravating the psychosis. Due to the fact that drugs always cause either hallucinations or delusions, the impacts caused by these drugs could be related to the extremes of suicidal behaviours. As such, these patients are always in need for behaviour management while in the psychiatric institution. Based on that, these findings reveal that nursing management strategies (nurse’s training as well as knowledge of screening and assessment of dual diagnosis in patients) while dealing with psychotic patients should be improved and/ or advanced so as to improve treatment and service to the patient. Lastly, nurses can be in a position to learn by understanding and working with service users experiences so as to offer optimum care to the patients. Search study The search strategy was based on the following key words: “Nursing management of patients with psychosis”; “comorbidity”; “Psychosis”; “Acute intoxication of patients with psychosis”; “drugs that propagate psychosis”. It should also be noted that these key words were used in one or more combinations so as to gain more data into the topic being discussed. The databases used so as to retrieve the data and/ or information in this research evaluation included: British Nursing Index (BNI) and the Royal College of Nursing. The period used for the search strategy was 2009 to 2014. The British Nursing Index revealed 4 relevant review articles and 20 relevant research articles while the Royal College of Nursing revealed 3 relevant review articles and 10 relevant research articles. Based on that, the search results that were not relevant to the topic of discussion were discarded. Moreover, older research review studies dated 2008 and before were also discarded. The inclusion and exclusion criteria are noted below in Table 1 below. In addition to that other evidence based resources that were used included: The National Institute for Health and Clinical Excellence (NICE); The Oxford Journals; The British Journal of Psychiatry; Cambridge University Press; Royal College of Psychiatrists; The European Journal of psychiatry; The Department of Health (DoH); Royal College of Nursing. These sources were accessed through the Google Search Engine and/ or Google Scholar. The nations included in the search were mostly in United Kingdom such as Finland and Ireland. Table 1 search strategy inclusion and exclusion criteria Inclusion criteria Exclusion criteria Keywords: “Nursing management of patients with psychosis”; “comorbidity”; “Psychosis”; “Acute intoxication of patients with psychosis”; “drugs that propagate psychosis”. Literature reviews from UK and whose period was from 2009 to 2014. Evidence from National Health organisations in the UK and Government websites. Literature that represents elder population of individuals aged 28 and above regardless of gender and ethnicity. Literature review and articles from 2008 and before. Literature not based on older population – majorly includes younger population. Literature not available in English. Websites with no relevant information that is not cited from other reliable sources. Literature Review – Discussion of the themes The themes outlined included: the relationship between substance abuse and individuals with mental illness such as psychosis – this could also be related to the relationship between dual diagnosis; the importance of nurse’s training as well as knowledge of screening and assessment of dual diagnosis in patients; the importance of understanding and working with service users experiences. Relationship between substance abuse and individuals with mental illness such as psychosis According to a research study in the UK, it was established that substance abuse led to relapses, hospitalization and in some instances acquisition of the different psychosis variants such as schizophrenia. The prevalence of substance abuse by mental illness patients in the UK was noted to be extremely high. The most commonly used substances were nicotine and alcohol among individuals who were in their late teens to 24 years old. The prevalence of alcohol was established to be 25% of the entire mental illness population. The prevalence of illicit drugs was noted to be 35% where the age groups involved ranged from 16 to 59 years. Cannabis was noted to have a prevalence rate of 8% in individuals aged 16 to 59. In a research study that was conducted to establish the association between substance abuse and individuals with mental illnesses such as psychosis, it was established that they did so in a bid to alleviate the psychological symptoms of the disorder (Crome and Chambers, 2009). No limitations were mentioned by the authors of the study. Kolliakou et al. (2011) conducted an evidence review study on the prevalence of cannabis abuse by patients with psychotic patients. The limitations of the study were that it did not establish whether psychotic patients were willing to stop its usage. The results revealed that psychotic patients used cannabis to: “get high”; feel relaxed and calm; induce the psychotic symptoms they were undergoing. This study was supported by Koskinen et al. (2010) when a Meta analysis study in Finland revealed that a larger number of the schizophrenia patients had been screened and diagnosed with cannabis use disorders (CUDs). In addition, it was common in the younger patients as well as those who were experiencing their fist episode. Moreover, males had a higher likelihood of acquiring the disorder. The methodology used was peer review articles and journals. The results were: median rate of CUDs was 16% and median lifetime rate was 27.1%. Moreover, for the first episode vs. concurrent episodes, median rate was 28.6% and 22% respectively. While the lifetime rate for the first episode vs. concurrent episodes was 44.4% and 12.2% respectively. Based on gender, two thirds were males. In younger as compared to older people the median rate was 38.5% and 16.0% respectively while the medial lifetime rates were 45.0% in younger participants and 17.9% in older participants. No limitations were mentioned by the authors of the study. Healey et al. (2009) conducted a qualitative investigation and the thematic analysis of the responses from the participants were related to: experimenting on the effects of using drugs and not using drugs; serious mental illness; substance effects; to feel normal and to manage stress related to the symptoms. The sample involved 15 patients who either had bipolar disorder and a history of substance abuse disorder. The limitations of the study were that the prevalence could not be determined and the study was not focussed on populations with different norms. The importance of nurse’s training as well as knowledge of screening and assessment of dual diagnosis in patients All nurses and/ or medical practitioners should have the adequate knowledge and training (NMC, 2010) for screening and the assessment of dual diagnosis so as to achieve optimized diagnostic outcomes. According to s study that was conducted by Crome and Chambers (2009), the nurse or care giver should seek to: ensure that they are flexible, understanding and empathetic to the patient needs; non judgemental of the patient’s choices; build clinical relationships with the patient so as to foster a social behaviour in the patient; motivate the patient so as to better deal with their disorder (s); impact knowledge to the patient about their disorder, challenges and solutions that could be implemented. In the qualitative study by Healey et al. (2009), it was revealed that motivating the patient to stop their substance abuse required the nurse or care giver to relate to the bipolar patient based on their previous and personal experiences. A review of empirical evidence by Horsfall et al. (2009) and a randomised controlled trial by Barrowclough et al. (2010) supported Healey et al. (2009) and added that: cognitive therapy, behavioural therapy, relapse prevention, case management and contingency management were effective as a nursing intervention method. Farren et al. (2013) conducted a longitudinal study in Ireland to investigate the prognostic factors that relate to a two year results of a group of patients who were alcohol dependent and they also had bipolar disorder or depression. The treatment strategies’ duration was four weeks where the study was specifically an inpatient treatment cohort of the dual affective disorder as well as the alcohol dependent patients. The results of the treatments were undertaken in a sequence of 3 months, 6 months and finally 2 years. Out of the 189 participants, 101 had depression while 88 had bipolar disorder. It was revealed that 6 months abstinence encouraged the patient to abstain for up to 2 years with a retention rate of 76%. In addition, bipolar abstainers were better off at managing their drinking as compared to depressed abstainers. Moreover, the younger participants (18–30 years) did not manage their drinking per day rates as compared to the older participant (51 years and above) after a period of two years. Lastly, female patients performed better at abstaining after two years as compared to men. The conclusion of this study was that intensive intervention helped the patient to improve and abstain from substance abuse. In addition, following up on the patient was essential at recording their growth with time as well as motivating them on the growth that they have so far made. The limitations of this study were not mentioned by the author. In similar evidence based research study that was conducted by Kelly et al. (2012) on the treatments that clinicians should implement with patients who have substance use disorders (SUD) as well as non substance use disorders, it was established that psychotherapies, behavioural interventions as well as pharmacological interventions were better placed at handling comorbidity for patients who had a schizophrenia and they were engaging in the use of cannabis. The limitations of this study were not outlined by the author. Moreover, an evidence based research study that was conducted by Volkow (2009) supported the research by Kelly et al. (2012) and added that approximately 50% of people who have schizophrenia are highly affected by SUDs – as such, they has comorbidity. Berry et al. (2013) conducted a research study to analyse the impact of patient empowerment on individuals who had a dual diagnosis of substance diagnosis and schizophrenia. The methodology involved a randomized experiment for the Motivational Interviewing for Drug and Alcohol misuse in schizophrenia or psychosis (MIDAS). Moreover, the study also involved a 12 and 24 month follow up of the patient. The results of the study included a three (3) factor empowerment model: power and anger; activism; self efficacy and control. The limitations of the study were not outlined by the author. However, the conclusion was that patient empowerment by the nurse or the care giver was essential for patient recovery. Despite the fact that nurses and/ or care givers should have knowledge and skills in dealing with patients with comorbidity, a review study that was conducted by Adams (2008), revealed that not all care givers may tend to project empathy and a non judgemental attitude to patients with substance disorders and mental illness. This is due to the reason that, some of them may have attitudes toward these patients and this would hinder their full recovery index. The importance of understanding and working with service users experiences It is without doubt that a large number of people who have mental challenges such as psychosis tend to also have co-occurrence of other disorders such as substance abuse disorders especially alcohol and other drug (AOD) disorders. As such, these people tend to have serious physical, social as well as psychological challenges while dealing with their multiple disorders. In turn, this may also tend to affect their treatment options that their nurses may have designed for them. In an empirical research study that was conducted by Streling et al. (2011), it was revealed that despite the challenges that are caused by multiple disorders, nurses’ and care givers would depend on past experiences in dealing with such patients. This is due to the reason that, they could be strategized for different treatment plans that have been used before and improved on so as to optimize on clinical and diagnostic outcomes. Despite that, there are also a number of challenges and/ or barriers that could hinder the implementation of different treatment options and/ or procedures. These include: nurse’s difference in education as well as their knowledge and training skills in dealing with the disorder; organizational challenges as to which treatment options should be implemented with the patient and what should not be implemented; financial constraints on the methods to be implemented – that is if they need to be funded or not; the stigma associated with drug abuse disorders as well as co-occurring disorders diagnosis. Based on that, a number of mental institutions are still trying to resolve this issue by coming up with usable solutions that could be implemented without causing issues in their implementation. Based on that, the aspect of understanding and working with other skilled service users’ experiences comes into play since the care provider could only implement techniques and methodologies that have been previously used and have been noted to be successful. Bibliography Adams, M. W. (2008). Comorbidity of mental health and substance misuse problems: a review of workers’ reported attitudes and perceptions. Journal of Psychiatric and Mental Health Nursing. 15, pp. 101–108 Berry, K., et al. (2013). Perceived empowerment in people with a dual diagnosis of schizophrenia spectrum disorder and substance misuse. Social psychiatry and psychiatric epidemiology, pp. 1-8. Barrowclough, C., et al. (2010). Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial. British medical Journal. p. 341. Crome, I., and Chambers, P. (2009). The Relationship between Dual Diagnosis - Substance Misuse and Dealing with Mental Health Issues: Research Briefing, Issue 30. [Online] Available from: http://www.scie.org.uk/publications/briefings/files/briefing30.pdf [Accessed: 13 April 2014]. Casadio, P., Fernandes, C., Murray, R. M., and Di Forti, M. (2011). Cannabis use in young people: the risk for schizophrenia. Neuroscience & Biobehavioral Reviews. 35(8), pp. 1779-1787. Camden and Islington NHS Foundation Trust (Candi.NHS UK). (N.d).Types of psychosis. [Online] Available from: http://www.candi.nhs.uk/eis/about-psychosis/types-of-psychosis/ [Accessed: 13 April 2014]. Douglas, K. S., Guy, L. S., and Hart, S. D. (2009). Psychosis as a risk factor for violence to others: a meta-analysis. Psychological bulletin. 135(5), p. 679. Di Forti, M., et al. (2009). High-potency cannabis and the risk of psychosis. The British Journal of Psychiatry. 195(6), pp. 488-491. Farren, C. K., Snee, L., Daly, P., and McElroy, S. (2013). Prognostic factors of 2-year outcomes of patients with comorbid bipolar disorder or depression with alcohol dependence: importance of early abstinence. Alcohol and alcoholism. The Oxford Journal. 48(1), pp. 93-98. Frisher, M., Crome, I., Martino, O., and Croft, P. (2009). Assessing the impact of cannabis use on trends in diagnosed schizophrenia in the United Kingdom from 1996 to 2005. Schizophrenia Research. 113(2), pp. 123-128. Frisher, M., Martino, O. I., Bashford, J., Crome, I., and Croft, P. (2013). Incidence of psychoses among drug dependent patients in primary care with no psychiatric history: a retrospective observational matched-cohort study. The European Journal of Psychiatry. 27(4), pp. 240-247. Harley, M., et al. (2010). Cannabis use and childhood trauma interact additively to increase the risk of psychotic symptoms in adolescence. Psychological medicine: Cambridge University Press. 40 (10), pp. 1627-1634. Healey, C., et al. (2009). Reasons for substance use in dual diagnosis bipolar disorder and substance use disorders: A qualitative study. Journal of affective disorders. 113(1), pp. 118-126. Horsfall, J., et al. (2009). Psychosocial Treatments for People with Co-occurring Severe Mental Illnesses and Substance Use Disorders (Dual Diagnosis): A Review of Empirical Evidence. Harvard Review of Psychiatry. 17 (1), pp. 24-34. Kelly, T. M., Daley, D. C., and Douaihy, A. B. (2012). Treatment of substance abusing patients with comorbid psychiatric disorders. Addictive behaviours. 37(1), pp. 11-24. Kelleher, I., and Cannon, M. (2011). Psychotic-like experiences in the general population: characterizing a high-risk group for psychosis. Psychological medicine. Cambridge University Press. 41(1), p. 1. Kolliakou, A., et al. (2011). Why do patients with psychosis use cannabis and are they ready to change their use?. International Journal of Developmental Neuroscience. 29(3), pp. 335-346. Koskinen, J., et al. (2010). Rate of cannabis use disorders in clinical samples of patients with schizophrenia: a meta-analysis. Schizophrenia bulletin. 36(6), pp. 1115-1130. Mind. (2013). Psychosis. [Online] Available from: http://www.mind.org.uk/information-support/types-of-mental-health-problems/psychosis/#.U2T7taJp5dg [Accessed: 13 April 2014]. Mind Health Care. (April 2014). Psychosis. [Online] Available from: http://www.mentalhealthcare.org.uk/what_is_psychosis [Accessed: 13 April 2014]. National Health Service (NHS UK). (May 2012). Psychosis. [Online] Available from: http://www.nhs.uk/conditions/Psychosis/Pages/Introduction.aspx [Accessed: 13 April 2014]. Nursing and Mid Wifery Council (NMC). (2010). Report for Nursing and Midwifery Council on nursing skills for working with people with a mental health diagnosis. [Online] Available from: http://www.nmc-uk.org/Documents/Consultations/RPNE/Report%20for%20Nursing%20and%20Midwifery%20Council%20on%20nursing%20skills%20for%20working%20with%20people%20with%20a%20mental%20health%20diagnosis.pdf [Accessed: 13 April 2014]. Owen, M. J., O’Donovan, M. C., Thapar, A., and Craddock, N. (2011). Neurodevelopmental hypothesis of schizophrenia. The British Journal of Psychiatry. 198(3), pp. 173-175. Royal College of Psychiatrists (RCPsych). (April 2013). Severe mental illness (psychosis). [Online] Available from: http://www.rcpsych.ac.uk/healthadvice/partnersincarecampaign/severementalillness.aspx [Accessed: 13 April 2014]. The Department of Health (DoH). (February 2011). Systematic Review of the Incidence and Prevalence of Schizophrenia and Other Psychoses in England. [Online] Available from: http://www.psychiatry.cam.ac.uk/wp-content/uploads/2011/09/ON7_Final_report_v1.04_Feb_2011.pdf [Accessed: 13 April 2014]. Volkow, N. D. (2009). Substance use disorders in schizophrenia—clinical implications of comorbidity. Schizophrenia bulletin. 35(3), pp. 469-472. Welham, J., Scott, J., Williams, G., Najman, J., Bor, W., OCallaghan, M., and McGrath, J. (2009). Emotional and behavioural antecedents of young adults who screen positive for non-affective psychosis: a 21-year birth cohort study. Psychological medicine. Cambridge University Press. 39(4), p. 625. Read More