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PubMed2005

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues.

BACKGROUND: Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach. METHOD: A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID. RESULTS: There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

Adolescent↗

PubMed1994

Volunteers in an HIV social care organization.

This study describes volunteers who were trained at a large HIV social care centre in South London during its first two years of operation. Many shared similar backgrounds to their clients; indeed some service users were also volunteers. Common motivations for volunteering were to learn more about HIV, to give something back to affected communities, and for gaining job-relevant experience. Selection, training and induction procedures were elaborate. But there were problems. Turnover was high, with half the volunteers dropping out in their first year. This matches reports for HIV organizations elsewhere, but is higher than for the voluntary sector in general. The high rate is attributed not to the nature of the work, but partly to the unusual social groups from whom volunteers are drawn and partly to the changing relationships between volunteers and the organization, symptomatic of which was loss of communication with staff and managers, and a consequent feeling of being undervalued. This can be linked to pressures arising from the pace of change in such organizations which have had the effect of marginalizing the role of volunteers. The new contractual arrangements with statutory agencies are contributing to the alienation, though ironically they were intended to strengthen the voluntary sector. The study questions whether AIDS service organizations should accept that the voluntaristic basis on which many originated is now over.

Acquired Immunodeficiency Syndrome↗

PubMed2005

The autonomy of professionals and the involvement of patients and families.

PURPOSE OF REVIEW: The involvement of patients/service users and their families/caregivers in the field of mental health has been of interest for several years. It is timely to review what has been learned about involvement; to understand where and how involvement has been implemented; and to explore factors which influence the effectiveness of implementation. Recent literature on user involvement and its implications for professional practice forms the focus of this review. Material is drawn largely from Europe, North America and Australasia, since this reflects where there is most interest in this topic. Papers outside of mental health are included where they further illuminate issues under discussion. RECENT FINDINGS: The involvement of users/patients and their caregivers is an important aspect of the care and treatment of mental illness extending across health and social care. Involvement has implications for professional practice including the negotiation of treatment, the coordination of care and communication strategies. Tensions may emerge during the process of effectively implementing patient/family involvement, but the autonomy of professionals is not usually a factor. SUMMARY: There is no singular definition of involvement. There has been growth in the levels of user/caregiver involvement, particularly in community-based provision and within transition processes from hospital to community-based treatment. There is no suggestion that involvement is widespread. Implementation of involvement should be underpinned by effective communication on the part of professionals and recognition of service users and caregivers as partners in processes of treatment and recovery. Implementation is most effective when supported by appropriate organizational policies and integrated into the education of health professionals.

Journal Article↗

PubMed2004

A Delphi study to identify performance indicators for emergency medicine.

OBJECTIVES: The aim of this study was to identify performance indicators thought to reflect the quality of patient care in the emergency department. METHODS: A three round accelerated Expert Delphi study was conducted by email or fax. A panel of 33 experts drawn from the fields of emergency medicine, emergency nursing, professional service users, and patients were consulted. Participants were initially asked to propose performance indicators that reflected the quality of care given in the emergency department setting in the United Kingdom. In the second round these proposals were collated and scored using a 9 point Likert scale; those that had not reached consensus were returned for reconsideration in the light of group opinion. Those statements reaching a pre-defined consensus were identified. RESULTS: 224 performance indicators were proposed. Altogether 36 indicators reached consensus reflecting good departmental performance after round three; 24 of these were process measures. CONCLUSIONS: 36 potential indicators of good quality of care in the emergency department in the UK have been identified.

Delphi Technique↗

PubMed2003

Partnership in coping: an Australian system of mental health nursing.

The paper identifies shortcomings of approaches used in organizing and delivering mental health nursing. It provides a rationale for the development of a new system of mental health nursing namely the Partnership in Coping system (PinC). This system has been developed by service users, clinical mental health nurses and an academic mental health nurse. Currently, it is undergoing trials in Western Australia. The PinC focuses on the strengths of clients. It uses the positive aspects of mental health nursing namely its holistic perspective, the length and nature of the informal contacts, the 'ordinariness' of relationships with clients and the nurse's knowledge of the clients' social and physical environments. It is a versatile system that can also be used across different mental health settings (community and inpatient facilities). The paper describes the philosophy behind the system, the concept of coping, the nature of the partnership between the client and nurse and their respective roles.

Adaptation, Psychological↗

PubMed1998

Evaluating the Cancer Information Service: a model for health communications. Part 1.

The Cancer Information Service (CIS) was established in 1975 by the National Cancer Institute (NCI) to meet the information needs of cancer patients, their families, health professionals, and the public. As the nation's foremost source for cancer information, the CIS applies a unique health communications model to bring the latest research findings on cancer prevention, detection, treatment, and supportive care to the nation. It does this through two main program components: a toll-free telephone service (1-800-4-CANCER) and an outreach program that focuses on providing technical assistance, specifically to partners reaching minority and underserved audiences. During its 22-year history, more than 7.5 million callers have reached the CIS telephone service. In addition, 100,000 requests are received each year from 4,500 organizations nationwide seeking cancer-related outreach expertise. This overview describes the CIS model for health communications, describes the program's impact in broad terms, and defines the critical role evaluation plays in each program component. The overview describes two customer satisfaction and impact surveys performed by an independent survey research firm in 1996 to evaluate the CIS model: (a) the telephone service user survey, a random sample of 2,489 persons representing major caller groups who were interviewed 3 to 6 weeks after their initial call to the CIS; and (b) the outreach partner survey, a random sample of 867 partner organizations, the majority of which reach minority and underserved audiences with information and programs, surveyed within a few months after a contact with the CIS outreach program. Impact data for both program areas were favorable: Approximately 8 out of 10 CIS callers reported that the information they received had a positive impact (either in eliciting a positive action [56%] or in reassurance of decisions made [22%]) and two-thirds of CIS partners said the CIS has an important impact on their programs.

Consumer Behavior↗

PubMed2001

How do we facilitate carers' involvement in decision making?

BACKGROUND: Government health care policy urges service providers to involve service users in the decision-making process. Research studies have recommended changes to current health care practice to facilitate this involvement. However, carers' organizations continue to highlight a gap between policy and practice in relation to involvement. AIM: The aim of the study reported on in this paper was to investigate involvement in a specific health care context with a view to identifying both opportunities for change and practical, realistic ways of bringing about that change. This was a qualitative case study using a case study design. The field site selected was a respite and assessment (23 bedded) ward within the Psychiatric Unit of a hospital specializing in the care of older people. Informal carers (n=20) and members of the multidisciplinary team (n=29) were interviewed about their views and experiences. The interviews were audiorecorded and transcribed. Family meetings, multidisciplinary team meetings and ward routines were the focus of non-participant observation. Field notes from these observations, together with the interview data were analysed using constant comparative method. RESULTS AND CONCLUSIONS: The reported experiences of carers in this study highlighted four markers of satisfactory involvement: feeling that information is shared; feeling included in decision making; feeling that there is someone you can contact when you need to; and feeling that the service is responsive to your needs. The majority of carers felt dissatisfied with the level of involvement. The situation we found echoed that found in other studies, i.e. the majority of informal carers (henceforth 'carers') interviewed were dissatisfied with the level of their involvement. However, our investigation, in which the views of health care professionals as well as those of carers were sought, provided invaluable insight into why this might be the case. Two main sources of difficulty were found: hospital systems and processes, and the relationship between nursing staff and carers. The argument made is that practitioners themselves must notice and challenge these barriers if carer involvement is to be facilitated.

Aged↗

PubMed1994

Will subsidiarity work for long-term care?

New financial and organization arrangements are changing the distribution of authority and power in the public service affecting managers, professionals and governing committees. The need for new roles like budget holding general practitioners, advocates, brokers and care managers are becoming recognized; traditional professional practice based on narrowly defined skills with the danger of a no-man's land between them is giving way to management arrangements that offer greater recognition of the needs of service users and their families. If the role of care manager and the new arrangements for assessment occur, much of the power now exercised by local authority members and by centrally based managers in local government will in the long-term be devolved locally to care managers. Various key issues are identified. Comprehensive multi-professional assessment is vital, with the results available to all groups of professionals so that a common voice can be presented to government circles in the future. Three broad areas need to be considered in the future implementation of long-term care. Firstly, some of the implications for assessment processes of the changes now taking place in community care will be described. Factors that inhibit good assessment will be discussed as well as key issues that also need to be addressed.

Community Health Services↗

PubMed2005

Perceptions on individualized approaches to mental health care.

Ways of working on acute psychiatric units have come under intense scrutiny in order for service users to receive modern care and treatment. This has led to various ways not only to improve the therapeutic milieu on psychiatric wards, but also to develop standardized approaches to care. This paper reports on a study on the development of a care pathway for people diagnosed with schizophrenia, with the aim of standardizing the care process. Action research was used to develop the care pathway and views were collected, and observations made from a range of mental health professionals. Not all respondents were in agreement with a care pathway and this led to clinicians defending the individualized nature of psychiatric care. Implementation of a care pathway may help not only to rekindle the therapeutic purpose of psychiatric care, but also to build in the individualized approach to carrying out hospital care. Limitations of the study have also been briefly reported.

Acute Disease↗

PubMed1986

Use of psychiatric drug treatment services by heroin users from general practice.

Centres for the treatment of drug abusers are often integrated with regional psychiatric hospitals and are the focus of the British response to opiate addiction. Little is known, however, about the use made of these services by drug users in the community or about the success of these services. This study examined the use made of one centre offering a detoxification service by a cohort of 183 heroin users from a large Scottish general practice. Over half of this cohort were referred to the psychiatric drug treatment service, but less than one third started treatment. The evidence did not indicate that patients who had extended contact with the psychiatric service showed prolonged abstinence, though methodological difficulties necessitate further prospective studies. This study raises important questions about the value and appropriateness of this type of service in the light of the pattern of voluntary remission and relapse displayed by heroin users and in the absence of adequate provision for drug abusers in the community.

Heroin↗

PubMed1996

[Evaluation of health information in newspapers and brochures. What can we believe?].

Health service users need reliable information to be able to make informed decisions. We evaluated the scientific quality of information presented at a large health fair in Oslo in 1995 and health-related articles in five newspapers during one week in the spring of 1995. The brochures scored consistently low on the index used to measure scientific quality. It was generally impossible to distinguish opinions from facts, or to assess the validity and consistency of the evidence underlying the conveyed information. Important consequences (benefits, risks and costs) were rarely assessed. Health-related articles in the lay press also scored low on the index. Minor changes could have led to marked improvement of some of the articles. It is important to improve the ability of journalists and producers of brochures to appraise their work in a critical light.

Advertising↗

PubMed2003

Perceptions on the development of a care pathway for people diagnosed with schizophrenia on acute psychiatric units.

Policy development and practice for hospital mental health care has shifted towards a user-focused and evidence-based direction. Important within this policy development has been a guideline for inpatient care, particularly the establishment of an inpatient Acute Care Forum. A vehicle to both commission and develop this agenda is the Implementation of a care pathway. A research study was designed to explore how a care pathway could be developed for inpatients diagnosed with schizophrenia. Interviews with a range of health care professionals and observation of the process of care pathway development were the data-collection tools. Analysis was driven by emergent themes across the data set. Themes were then presented as one possible interpretation of the factors to be considered for the development of a care pathway for people diagnosed with schizophrenia. Clinicians experienced many difficulties in finding and including evidence-based practice (EBP) within a care pathway. Professions on the whole felt that there was a certain futility to psychiatric care given the paucity of evidence to support practice. This may contribute towards the poor use of hospital care as a therapeutic intervention as part of the wider spectrum of care. Difficulties arise when trying to develop a care pathway with EBP, given the paucity of knowledge on why certain interventions are only partially effective. The development of a care pathway may inform the priorities of the inpatient Acute Care Forum for people diagnosed with schizophrenia. A care pathway should not be constrained, however, to EBP and should incorporate therapeutic activities to improve the overall experience of service users. Limitations on the study and the collection of evidence supporting these conclusions conclude the paper.

Attitude of Health Personnel↗

PubMed2000

Quality Enhancement Research Initiative in Mental Health.

The Veterans Administration (VA) recently introduced its Quality Enhancement Research Initiative (QUERI) to facilitate the translation of best practices into usual clinical care. The Mental Health QUERI (MHQ) was charged with developing strategic plans for major depressive disorder (MDD) and schizophrenia. Twenty percent or more of VA service users are affected by 1 of these 2 disorders, disorders that often have a devastating impact on affected individuals. Despite the increasing availability of efficacious treatments for each disorder, substantial gaps remain between best practices and routine care. In this context, the MHQ identified steps critical to the success of a sustained process of rapid-cycle health care improvement for MDD and schizophrenia, including research initiatives to close gaps in knowledge of best treatment practices, demonstration projects to close gaps in practice and to expand understanding of effective strategies for implementing clinical guidelines, targeted enhancements of the VA information system, and research and dissemination initiatives to increase the availability of resources to support the accelerated incorporation of best practices into routine care. This article presents an overview of the elements in the initial MHQ strategic plans and the rationale behind them.

Benchmarking↗

PubMed2002

Developing and testing methods for improving patient-oriented mental health care.

There is a trend in nursing policy and practice towards allowing patients to participate actively in their treatment and the services they use. The author concludes, based on an earlier qualitative study, that psychiatric patients in a hospital environment want a more active role in their treatment and that psychiatric nurses also aim at more active patient participation. In mental health care, professionals often define the needs of patients in terms of their own expertise and tend to overlook the variety of the service users' needs. The need to improve and empower psychiatric patients is a considerable challenge to present-day nursing. The purpose of this paper is to describe the theoretical background of tools used to assess patients' involvement in mental health care and the process by which credibility can be determined in rating the panel phase of instrument construction. The instruments, based on a qualitative study using grounded theory, produced a model of patient initiatives in psychiatric nursing. Content validity refers to the determination of the substantive representativeness or relevance of the items of an instrument. Face validity has been defined as validity conferred by a lay persons' acceptance that a procedure, statement or instrument appears to be sound or relevant. In the panel rating, the raters were experts. They evaluated the readability, consistency and content validity of the instruments' items. In the instrument for nurses, the content validity was 0.84 and consistency 0.91; this corresponds to 0.91 and 0.95, respectively, in the instrument for patients.

Humans↗

PubMed2005

Community nurses' talk of equality and the discursive constitution of selves.

AIM: The aim of this paper is to explore how stories revealed the discursive constitution of particular selves and to consider the implications for future understandings of equality and practice. BACKGROUND: Equality has long been an objective of most Western healthcare systems, as enshrined in the principles of equal rights to access, treatment and care. Service users, however, continue to experience inequities, oppression and discrimination. These continuing inequalities have resulted in demands for nurses to tackle discrimination and oppression and promote equality in their practice. METHODS: Semi-structured interviews were conducted with 14 community nurse students and 14 practice teachers from two universities in England in 1998. Discourse analysis was used to interpret the narratives. FINDINGS: Community nurses were actively positioning themselves and were being positioned through dominant and competing discourses. Their narratives revealed stories of equality in health care that were contingent upon complex discursively constituted selves. They were found to take up, rework and in some cases subvert and reject dominant subject positions. The implications of these selves are considered in relation to the development of equality and practice. CONCLUSIONS: Educationalists and practitioners need to engage with these discourses and diverse selves and begin to develop approaches which remain open to scrutiny and challenge so that specific and localized understandings of equality and practice can evolve.

Attitude of Health Personnel↗

PubMed2003

Impacts on practitioners of using research-based carer assessment tools: experiences from the UK, Canada and Sweden, with insights from Australia.

Researchers and practitioners in several Western countries have recently developed tools for assessing the situation of the carers of adults who are ill, elderly or have disabilities. The present article describes the impact of three such assessment tools, from Canada, the UK and Sweden, on the professional practice of assessors. All tools were tested in agency-based studies. Focus groups, workshops and interviews with assessors were employed to understand the impact on professionals and their practice. An Australian researcher and case manager comments on these experiences from her unique perspective. The results reveal that the use of carer assessments can lead to changes in the appropriateness of intervention by informing practitioners of issues which are given little attention, but which impact on the adequacy of interventions to the service user. Across the projects, most workers found that the tools facilitated a more comprehensive, in-depth and carer-focused assessment. Experience across all the projects suggests that, used sensitively, such tools and approaches can play a key role in transforming the relationship between carers, and the health and social care system. Giving carers a legitimate voice, acknowledging their perspective and expertise, and making them central to assessment processes accords them status both as active partners, and as individuals with their own needs and aspirations, rather than seeing them primarily as resources. As a result of their experiences, many workers and administrators concluded that home-care programmes must change their mandate to include carers among their clients, raising the issue of available monetary and human resources to meet the needs of this group. In addition, as our Australian colleague points out, time, efficiency, relevance, benefit and minimal intrusiveness are important factors for practitioners which influence their use of assessment tools.

Aged↗

PubMed1991

Home detoxification from alcohol: its safety and efficacy in comparison with inpatient care.

The safety and short-term effectiveness of home detoxification (HD) was investigated by contrasting rates of treatment completion and of complications of 41 service users with those of a retrospectively matched inpatient comparison group. The latter comprised patients of a detoxification unit matched for age, sex and degree of alcohol dependence with HD subjects. HD subjects had severe problems with alcohol--they averaged 28.7 on the SADQ, 4.6 serious alcohol-related problems in the previous 2 months, a GGT of 123.8 and 174.6 reported units of alcohol consumed in the week before treatment. A high follow-up rate was achieved for both HD subjects and their relatives; there was close agreement between clients' reports, carers' reports and breathalyser readings with regard to further alcohol consumption. The HD subjects were visited at home an average of 6.9 times over 6.15 days. Chlormethiazole was prescribed in 36 cases at an average maximum daily dose of 6.3 capsules--significantly fewer than for the inpatient group. Both rates of completion and complication were virtually identical in the 2 groups. It is concluded that these data suggest HD is equivalent in both its safety and immediate efficacy to more expensive inpatient care.

Adult↗

PubMed2002

Inequalities in health care provision: the relationship between contemporary policy and contemporary practice in maternity services in England.

AIM: The project Addressing Inequalities in Health: new directions in midwifery education and practice (Hart et al. 2001) was commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB). Here, we draw on those research findings to consider current midwifery policy and practice in England. BACKGROUND: Little guidance on providing equality of care exists for midwives. The Code of Conduct [United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1992] makes no specific requirement for midwives to address issues of inequalities of health in their practice. Recent policy documents emphasize the need to work towards reducing inequalities and to target practice to 'disadvantaged clients' without giving guidelines on how to identify and care for target groups. METHODS: In-depth studies of midwifery education and service provision were conducted in three very different parts of England. Three months of fieldwork were undertaken at each site, comprising a series of interviews with midwifery educators, managers, students, midwives and service users. Focus groups were also held and observation of classroom sessions and midwifery practice undertaken. Findings. A lack of clear and specific strategies concerning inequalities in health was evident at managerial level. Patchy knowledge of current policy was also evident amongst practising midwives. Specific projects with disadvantaged clients usually resulted from a particular midwife's personal interest or evident local need. All midwives emphasized the importance of 'equality of care'. How this was operationalized varied, and 'individualized' or 'woman-centred' care was assumed to encompass the concept. In the few examples where care was systematically targeted in accordance with policy directives, the midwife's public health role was increased. CONCLUSION: In the absence of a co-ordinated strategic vision driven by managers, practitioners find difficulty in prioritizing care and targeting resources to disadvantaged clients in line with policy directives. Tensions between policy and practice in the care of 'disadvantaged' women clearly exist. Successful implementation of policy at practice level needs: commitment from managers; clarity of purpose in documentation; and provision of specific targets for practitioners. However, the latter should remain flexible enough for the delivery of care to be appropriate and sensitive to individual needs.

England↗