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PubMed2002

Information that informs rather than alienates families with disabled children: developing a model of good practice.

The importance to families with disabled children of relevant and accessible information about services has been illustrated in numerous studies and was re-emphasised by the Department of Health's 'quality protects' initiative. Indeed, the provision of information and the importance of keeping families informed is frequently viewed as a significant factor within both the concept of empowerment and the facilitation of enabling and participatory processes for service users and their families. However, although there has been considerable research highlighting parents' information needs, there has been significantly less exploration of how parents would actually like to receive this information. This paper seeks to bridge this knowledge gap and also discusses the empowering potential of user-friendly information. Drawing upon data collected from focus group discussions with parents caring for children with a range of disabilities or chronic illnesses, this paper explores how the families of service users would like to receive information. In particular, it examines the criteria by which parents judge the quality of information and their ideas as to what constitutes good practice, especially in terms of how information is presented, its content and the way it is delivered. Using these ideas and criteria, the paper begins to develop a model of good information practice that is both three-dimensional and personally interactive. Indeed, parents' desire for a combination of personal guidance and good-quality information, whether in the form of in-depth booklets or shorter directories, is viewed as being of paramount importance and, furthermore, as having an important empowering potential.

Benchmarking↗

PubMed2003

CONNECT: a measure of continuity of care in mental health services.

This paper introduces a measure of continuity of care (CONNECT) developed for mental health services research. CONNECT addresses qualities of interpersonal interaction in service-user/practitioner relationships through 13 scales and one single-item indicator. The scales are grouped into five domains: knowledge, flexibility, availability, coordination, and transitions. Domains were derived from ethnographic data. Service users rate responses to items using 5-point scales The measure is administered in interview format. CONNECT was developed for use with persons who have serious mental illness. Preliminary testing included cognitive interviews and two pilot studies. The results of a field test in which 400 persons with serious mental illness completed CONNECT indicate that the measure is easily administered and produces well-distributed responses. Five scales meet the .80 criterion for internal-consistency reliability for group-level research. Estimates of 2-week test-retest reliability indicate fair-to-good agreement. A broad initial validation strategy including known groups and convergent validity assessments produced results that will inform and focus future efforts. Next steps in the measure development process are discussed.

Adolescent↗

PubMed2004

The quest for well-being: a qualitative study of the experience of taking antipsychotic medication.

Antipsychotic medication is integral to the treatment of severe and enduring mental health problems (e.g. schizophrenia). Such medication is associated with significant adverse side effects that can affect treatment adherence. To date there have been few attempts to analyse qualitatively service users' experience of taking antipsychotic medication. This study, conducted in Exeter, South West England, investigates the subjective experience of side effects of antipsychotic medication to gain a greater understanding of service users' experiences and to gain insights into adherence issues. Data were analysed using a variant of grounded theory (Glaser and Strauss, 1967) and a model of the experience of taking antipsychotic medication was constructed. The interview schedule was then refined and further interviews (including a focus group) were conducted among a diverse sample recruited from local day centres. Results indicated that people taking antipsychotic medication do not see side effects and symptoms as separate issues. Instead, they describe drugs as 'good' or 'terrible'-an indication of the total impact of their treatment. The model constructed reflects this, having the core concept of Well-being: that is, normality of function, feeling and appearance to the outside world. Major themes relating to this core category were managing treatment, evaluating treatment and understanding of the situation. Implications for medication adherence and clinical practice, including drug choice, are discussed, and the doctor-patient relationship is also considered.

Adult↗

PubMed2001

International mental health outcomes and benchmarking using the FACE (functional analysis of care environments) approach.

This article describes and compares the nature and severity of problems encountered by persons receiving mental health services in the United Kingdom and Australia, and the outcome of their treatment. The perspective of service providers and service users in the two countries was strikingly similar. Treatment was effective in alleviating problems with social circumstances, and in increasing adaptive and interpersonal functioning. Treatment was less effective in addressing psychological or physical problems. Service users in the United Kingdom were more involved in developing their treatment care plan than those in Australia. The study demonstrates how data required for benchmarking and outcome evaluation purposes can be generated as part of routine clinical processes.

Activities of Daily Living↗

PubMed2005

The role for government health centers in provision of same-day voluntary HIV counseling and testing in Kenya.

OBJECTIVE: To explore the role of primary health centers in provision of voluntary counseling and testing (VCT) in Kenya. DESIGN AND SETTING: Prospective service evaluation at 3 (1 urban and 2 rural) government health centers. SUBJECTS: Consecutive adult clients. MAIN OUTCOME MEASURES: Uptake of services, user characteristics, quality of service. RESULTS: Counseling services received 2315 new clients over 26 months. The last quarter averaged 101 clients per clinic. More than 80% of clients lived locally. Overall 93% opted to test, 91% receiving results, 82% on the same day. Most clients tested HIV negative (81%). Youth and men were well represented. Few couples (10%) attended. Seventeen percent of women were pregnant. Self-referral was common and illness was an uncommon reason for testing (<20%). Thirty-one percent of clients were referred from VCT to other health center services. Counseling was perceived as high quality by users and providers. Validation of the test algorithm showed a sensitivity of 98.0% and specificity of 98.7%. CONCLUSION: Government health centers in Kenya can be appropriate providers of VCT. This pilot helped initiate a new strategy of health center-based VCT in Kenya and this has facilitated rapid expansion and more equitable provision for Kenyans.

Age Factors↗

PubMed1997

Patients' rights in England and the United States of America: The Patient's Charter and the New Jersey Patient Bill of Rights: a comparison.

The Patient's Charter has been in effect for nearly five years. This article considers the purpose and value of the document through a comparison with the New Jersey Patient Bill of Rights. Patient rights statements have been posted in American hospitals for more than twenty years. However, the New Jersey document and the patient rights programme it established seven years ago, have proven to be economically effective, successful in their representation of patients and enforceable, due to the adoption of state legislation and regulation to oversee the process. Several examples of how the programme works are included in the comparison, with a similar review of The Patient's Charter. In the comparison the author argues that for the programme to succeed as it has done in New Jersey, the government will need to develop legislative backing to ensure enforcement, and an efficient system for monitoring compliance. The programme will need to become credible in the eyes of the health service user. The author suggests this may be best achieved by developing an efficient, accessible and user-friendly means of redress, should the patient consider his or her rights have been violated. A "mish-mash" of quality assurance standards and levels of care which patients can "expect" from the health service providers only serves to distract the health service user from the government's failure to commit the resources that would empower the patients rights portion of The Patient's Charter.

Delivery of Health Care↗

PubMed2005

Observation: the original sin of mental health nursing?

The assessment and management of 'risk' has become a focal aspect of contemporary mental health practice. Given their proximal relationship with service users, nurses most often represent the 'front line' of risk management, typically expressed in hospital settings through the bureaucratic process of 'observation'. Much of the available 'evidence' is highly critical of this practice and service user researchers, in particular, have repeatedly called for alternatives. This paper reviews the historical and inter-professional dimensions of the practice of observation, contrasting this with mental health nursing's search over the past two decades, at least within the UK, for professional autonomy. Contemporary mental health nursing is trapped in an anachronistic relationship with psychiatric medicine. If nursing is to prosper, nurses must address the complex issues underlying this inter-professional relationship. The authors describe the development of 'bridging'--a radical alternative to observation practice, which represents a means of managing 'risk' and a way that nurses might develop their interpersonal relationships with people deemed to be at risk, thereby asserting the power of 'caring'.

Defensive Medicine↗

PubMed2005

The development and implementation of an educational intervention on first episode psychosis for primary care.

INTRODUCTION: This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis. METHOD: The Medical Research Council complex interventions framework was used to guide the development of the intervention. The theoretical phase included a literature review of previous educational interventions in primary care and consideration of the literature on attitude formation and change, and the relationship between attitudes and behaviour. The modelling phase included focus groups with GPs and service users, and a training needs analysis questionnaire administered to GPs. The 2-stage intervention consisted of a video featuring role-plays of primary care consultations, GP-led discussion and discussion with early intervention service users. The acceptability and utility of the educational programme was evaluated using a 5-point Likert scale questionnaire administered at the end of each session. RESULTS: General practitioners from each of the 39 intervention practices participated in the initial session and from 27 practices in the booster session. Information about symptoms and signs of first episode psychosis was the most valued aspect of the initial session. The booster session was also well received, with GPs valuing the opportunity to gain insight into first episode psychosis from users. CONCLUSIONS: This paper adds a pragmatic description to the literature on the development of educational interventions in primary care. The Medical Research Council framework helped to identify and clarify component parts of the intervention and how the active components may relate to the expected outcome of behaviour change.

Adolescent↗

PubMed1997

A comparison of three approaches to delivering a speech and language therapy service to people with learning disabilities.

This research aimed to compare three different approaches to delivering a speech and language therapy service to people with learning disabilities, in order to make recommendations for future service delivery. The three approaches all involved working with key communication partners in the environment. They were: (i) working directly on a one-to-one basis with the person and partner; (ii) working indirectly by providing teaching for partners; and (iii) a combination of these two approaches. A teaching course called 'Talkabout' was used. Talkabout aims for staff to reach a recognised level of knowledge and competence in communication skills, thus facilitating the communication skills of their service users. The results indicated that whilst communication changed in all three approaches, overall changes were greater in the combination approach. Only the combination approach demonstrated statistically significant differences following intervention, in terms of staff initiations, service user responses, and their use of additional modalities.

Delivery of Health Care↗

PubMed1997

A challenge for community psychiatric nursing: is there a future in primary health care?

The growing debate surrounding the role of the community psychiatric nurse (CPN) in the United Kingdom is reviewed. Issues which have attracted significant interest and which form the focus of this paper are the prioritization of CPN services, CPN attachment to primary health care (PHC), and the effectiveness of clinical interventions. The requirement for CPNs is now to concentrate services on people experiencing severe and enduring mental health problems. Innovative and effective clinical and social interventions for this client group are beginning to disseminate into everyday CPN practice. Problem-solving family interventions, cognitive therapies and case management are three such examples. The past, present and possible future role for CPNs working in primary health care settings with people experiencing nonpsychotic mental health problems is a particular focus in this paper. Drawing on the relevant literature, central issues addressed are the process and outcome of CPN work with nonpsychotic service users, reasons for the growth of CPN involvement in PHC, and the overall expansion of interest in mental health interventions within the primary health care environment. The literature suggests that this expansion has been strategically unplanned, but that mental health need amongst primary health care service users is significant. The concluding contention of this paper is that a future role for CPNs in primary care does exist.

Case Management↗

PubMed2004

Developing practice through the professional imagination.

How can the perspective of the service user be made real and helpful in the professional education of community nurses? This article presents one answer to this question through encouraging nurses to write fictional accounts of how their practice appears to their own service users. Arising from a research project on the "patchwork text" assignment format in a professional degree course at Anglia Polytechnic University, the article presents two such accounts by community nurses undertaking the course. Their accounts illustrate the insights into professional issues that are produced by an explicitly imaginative exercise. A particularly important outcome, not expected by the researchers, was that the commentaries written by the nurses on their imagined scenarios, led, not to a discussion of "issues" (as in many cases) but to a precise and practical critique of their actual practice, suggesting a further dimension of the educational value of writing fiction as part of professional education courses.

Attitude of Health Personnel↗

PubMed2005

Awareness and practice of complementary therapies in hospital and community settings within Essex in the United Kingdom.

Enhanced public interest calls for integration of Complementary treatments within allopathic medicine. The Foundation of Integrated Medicine issued guidelines for the use of complementary therapies in June 2003. The National Institute of Clinical Excellence (NICE) backed the use of Alternative Therapies in a paper in November 2003. The nursing and midwifery council (NMC) issued a position statement (December 2000) advocating all nurses and midwives using complementary or alternative therapies must ensure that they are individually competent to practice. For the service user, the NMC stipulated that these therapies needed to be safe and used as part of the therapeutic process. This included the recipient consenting to treatment. This has enabled nurses to expand their practice to integrate Complementary treatments into nursing care within the National Health Service. High-quality care is focused on client's individualized needs, based on current government initiatives (Making a Difference, 2000; Government response to the House of Lords select committee's report on complementary and alternative medicine, CM5124, The Stationary Office, London) (NHS Choice Agenda 2004). Following the Patient's charter (DoH, 1991) and the more recent NHS Plan (2001), service users are no longer intimidated by the authority-based structure and speak out against various decisions and the right to take part in decision-making. This study investigated the awareness of complementary therapies by healthcare professionals currently employed by a local healthcare Trust. Data were also gathered on qualifications in complementary therapy and hospital and community sites of practice. We found a mismatch between the referrals staff recommended to clients and the treatment available within the practice areas. On the basis of our findings, we developed a new policy [Richardson J, Brennan AM. Complementary therapies in the N.H.S. service development in a local district general hospital. Complement Ther Nursing Midwifery 1995;1:89-92] for the provision of complementary therapies within the local health service.

Attitude of Health Personnel↗

PubMedDate not supplied

How patient involvement in care is improving service provision.

An emphasis on public and service-user involvement runs through the core initiatives of the modernisation agenda as outlined in The NHS Plan (Department of Health, 2000) and related policy documents. This article discusses problems that have prevented the NHS from being responsive to the views of service users and what the implementation of policies can offer in terms of overcoming such problems. In addition, initiatives and other ways of identifying and delivering public or patient needs are considered.

Benchmarking↗

PubMed2005

Developing and piloting an audit tool for mental health education and training: the National Mental Health Education Continuous Quality Improvement Tool.

It is clear from the international literature that education and training can play a crucial role in improving the quality of mental health service delivery. In the UK, post-qualification mental health education and training is not generally allied to the national policy agenda and there is a lack of service user and carer involvement in the design, development and delivery of educational curricula. The Department of Health in England has funded the development of a continuous quality improvement tool to address these important concerns and help commissioners of mental health education and training evaluate key aspects of courses. The design of the tool was informed by the literature and a series of semi-structured interviews and focus groups with key stakeholders. Subsequent drafts were refined through steering group consultation and the instrument was then piloted within a selected region in England. This has resulted in a brief, user-friendly tool that takes into account the views of all stakeholders in mental health education programmes, promotes dialogue and facilitates continuous quality improvement. The tool promotes self-assessment of: partnership arrangements; the relevance of the programme to the policy context; the extent to which service users and carers are involved in the design, delivery and evaluation of programmes; and the assessment of the impact of the programme. Results from the initial implementation project (to be reported separately) suggest that the tool is welcomed and can complement existing quality mechanisms.

Health Occupations↗

PubMed1992

The effects of preferred provider options in fee-for-service plans on use of outpatient mental health services by three employee groups.

Descriptions of how preferred provider organizations (PPOs), offered as options to employees enrolled in fee-for-service plans, affected use of outpatient mental health services are provided. Data are from the RAND Preferred Provider Organization Study, which has a sample of employees who enrolled in fee-for-service plans 1 year before and 2 years after a PPO option was offered by three employers in two U.S. sites. To study effects of the optional PPOs on access to mental health care, usage patterns among those who initially stated that they did or did not intend to use PPO providers were examined. By the end of the second post-PPO year, employees had a similar annual probability of having an outpatient mental health visit whether or not they initially intended to use PPO providers. However, during the first post-PPO year, there was a decrease in the probability of use for those initially intending to use PPO providers, relative to those who did not intend to do so, among employees who had no regular medical provider. To study effects of the PPO option on usage levels of mental health care services, users of mental health services who primarily visited PPO were compared with those who primarily visited non-PPO providers. Users who visited PPO providers had significantly lower levels of use, controlling for other factors, than those who primarily visited non-PPO providers. Therefore, despite lower cost sharing for services received from PPO providers, the PPO option appeared to lower outpatient mental health care costs while having no more than a transient effect on access. This study did not evaluate mental health outcomes.

Adult↗

PubMed2004

Evaluating the impact of training in psychosocial interventions: a stakeholder approach to evaluation--part I.

A range of psychosocial interventions (PSI) have developed as approaches to the treatment and support of people with enduring mental health problems and their carers. The impact of training mental health workers in PSI has also been subject to extensive research and evaluation for the past decade. Most previous research in the PSI and PSI training arenas have tended to adopt quasi-experimental designs and professionally defined outcomes-focused approaches to judging the success of training. This paper offers a critique of such approaches and presents a rationale for the methodology used in a qualitative study that evaluated five short PSI courses. The study emphasized a stakeholder approach to evaluation, involving collaborative activities between service users, carers, lecturers and mental health workers. These activities were intended to define what outcomes should be used to judge the success of training and how these should be examined during the research process. This paper details the processes and findings of these stakeholder activities that suggested, for service users particularly, process rather than outcome issues were the most important determinants of the success of PSI. Additionally, if outcomes were used to judge the success of interventions these should be highly individualized to reflect the aspirations of the person receiving the intervention. On the basis of the findings presented, discussion explores a proposal for a different methodological direction to the evaluation of PSI training. Part II of this paper presents and discusses the findings from the evaluation of the courses.

Cooperative Behavior↗

PubMed2001

Consistency, context and confidence in judgements of affective communication in adults with profound intellectual and multiple disabilities.

Twenty-four service providers rated 12 video samples of four service users with whom they were familiar for affective behaviour (i.e. 'like'/'dislike') and confidence (i.e. 'certain'/'uncertain') in their judgement. Each video sample had been recorded as part of a stimulus preference assessment during which a wide range of specific stimuli were presented to each service user. Each video sample was presented twice in a counterbalanced design either with contextual information, i.e. what the presented stimulus was (C) or without such information, i.e. context free (CF). The observers showed considerable individual variation in their judgements, largely uninfluenced by the availability or otherwise of contextual information. However, as a group, observers significantly distinguished between video samples with regard to affective communication (determined through multiple analyses of variance) and the pattern of judgements, i.e. the relative judgement of positive or negative affect, from one sample to another. This showed a good level of consistency between observers (determined through principal components analysis). The impact of contextual information was not apparent for all video samples. However, contextual information significantly influenced judgements in four samples, typically making them more extreme; for example, a response indicative of positive affect in the CF situation became more positive when contextual information was provided, indicating that the stimulus was one that the participant was thought to like.

Adult↗

PubMed2002

Managing adverse drug reactions: an orphan task.

BACKGROUND: Nurse prescribing initiatives have potential to impact on medication management for long-term conditions. Over time, the adverse effects of medications become increasingly onerous. This 'side-effect burden' is particularly heavy for users of antipsychotic medication. Although consensus exists that strategies are needed to alleviate these problems, currently, they are not clearly the responsibility of any one professional group. AIM: This paper explores the introduction of nurse-administered evaluation checklists, in relation to nurse prescribing initiatives and division of professional responsibilities for medication management. METHODS: This was an observation study, with a quasi-experimental comparator group design, undertaken with clients receiving long-term antipsychotic medication. In both intervention and comparator groups, before and after introduction of evaluation checklists in the intervention group, 20 nurse-client interactions were observed. Problems actioned by the nurses, with and without the checklists, were compared. Stakeholders' views were sought concurrently. FINDINGS: Implementation of evaluation checklists increased the numbers of adverse effects detected and actioned by nurses. They also served to apportion aspects of medication management between nurses and medical prescribers. Most actions taken by nurses to alleviate adverse effects concerned clients' physical health and advice on health-promotion. However, the nurses' interventions would have been more effective had they been able to supply clients with certain medicines either by prescribing from the Nurse Prescribers' Formulary or issuing under Patient Group Directions. For some clients, ameliorating the adverse effects of medication would have involved changes to prescribed antipsychotic medication; here decisions were more equivocal. IMPLICATIONS: The identification of previously unattended problems, together with the views of service users, suggests that empowering nurses to address the 'care gaps' in medication management may benefit service users. The 'checklist evaluation' approach warrants further investigation, ideally in conjunction with nurse prescribing initiatives.

Adult↗