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'Silent and censured travellers'? Patients' narratives and patients' voices: perspectives on the history of mental illness since 1948.

This article seeks to demonstrate how patients' oral testimony can usefully contribute to--and challenge--the history of mental illness in the second half of the twentieth century, through the use of the concept of narrative frames. This work has emerged from a broader study which seeks to examine shifts and continuities in the experiences of mental illness from the introduction of the NHS to the present day, through a study of Oxfordshire. Psychiatry itself and the historiography of psychiatry have in many ways silenced the patient or service user. Nevertheless, acceptable means of communication have always existed, and these are revealed through patients' narratives. In-depth analysis of 21 interviews with patients has led to the emergence of three key acceptable narratives or narrative frames, these being: stories of loss, tales of survival and self-discovery, and narratives of the self as patient. Through examination of three key frames by which patients and users have understood and presented their illness experiences, this article seeks to trace the interactions between the general and the particular, the social and the individual, and to contribute to a more nuanced understanding of the recent history of mental health and illness.

Communication Methods, Total↗

FQHC (Federally Qualified Health Center): harnessing the incentives of cost reimbursement.

Community health centers (CHCs) are federally supported primary care providers to the low-income and uninsured. The federally qualified health center (FQHC) legislation requires states to pay CHCs for Medicaid services on the basis of reasonable cost. The statute generated controversy, particularly in a time when, for most providers, cost-related reimbursement has given way to fixed payments and managed care. This article examines the impact of FQHC on revenue and utilization of CHCs, using data for 328 centers that were in continuous operation between 1989 (the year the legislation was enacted) and 1992, the first year of full implementation. During this period, the CHCs Medicaid revenue grew rapidly. FQHC is estimated to account for under one third of the total increase, while inflation and growth in utilization due to expanded Medicaid eligibility are estimated to account for the other two thirds. At the same time, the change to cost-related reimbursement had a significant increase in total service users and Medicaid recipients receiving care from CHCs. Although some expected that cost-reimbursement would lead to inflationary increase in utilization, this did not occur. There was no statistically significant relationship between the change in payment methodology and changes in encounters per user. The experience of FQHC indicates that, for safety net providers of primary care, cost-related reimbursement is not "inherently inflationary." Results of this study raise the question of whether payment within constraints, but bearing relationship to cost, is not an appropriate approach to developing primary care capitation rates for these providers--and assuring maintenance of the safety net for the uninsured.

Community Health Centers↗

Dedicated online virtual reference instruction.

To facilitate nursing students' information literacy skills and enhance traditional library user services, academic librarians have developed synchronous (real-time) online virtual reference instruction in nursing research classes. The authors discuss collaborative efforts of nursing and library faculty in planning, implementing, and evaluating a discipline-specific virtual reference pilot program.

Computer-Assisted Instruction↗

Electroconvulsive therapy in Scottish clinical practice: a national audit of demographics, standards, and outcome.

OBJECTIVES: Many of the commonly expressed concerns about the effectiveness of electroconvulsive therapy (ECT) have been addressed by scientific studies. However, this has done little to reassure service users and the public at large about its use in routine clinical practice. This 3-year study between 1997 and 1999 consisted of a series of audit cycles to systematically answer questions about ECT demographics and outcome across Scotland. METHODS: Audit standards were agreed and each ECT clinic was visited at least twice to assess facilities and adherence to protocol as set down by the Royal College of Psychiatrists, UK. Demographics and outcome after ECT were measured during 2 9-month sample periods. Adequacy of teaching and supervision was assessed directly and by questionnaire. RESULTS: Facilities and equipment at ECT centers were up to date and generally of a high standard. ECT was given at a rate of 142 treatments per 100,000, mainly to white adult patients suffering from a depressive disorder. The ratio of females to males was approximately 2 to 1, and ECT was not given disproportionately to the elderly. 76% of patients were of informal status and 82% gave informed consent, with the remaining 18% receiving treatment under the safeguards of the Mental Health (Scotland) Act 1984. There was a definite clinical improvement with treatment, defined as at least a 50% fall in the Montgomery Asberg Depression Scale, in 71% of those treated for depressive illness. 65% of those treated for a non -depressive psychosis were rated as at least 'much improved' on the Clinical Global Impression scale. CONCLUSIONS: ECT given in routine clinical settings across Scotland meets Royal College of Psychiatrists standards and is an effective treatment of the clear majority of patients.

Adolescent↗

Childhood predictors of psychiatric disorders among boys: a prospective community-based follow-up study from age 8 years to early adulthood.

OBJECTIVE: To study early childhood predictors for early adulthood psychiatric disorders. METHOD: The sample included 2,712 Finnish boys born in 1981. Information about the 8-year-old boys' problem behavior was obtained from parents, teachers, and children. The 10-15-year follow-up information about psychiatric disorders in early adulthood was based on the national military register between the years 1999 and 2004. RESULTS: According to the military register, 10.4% of men had a psychiatric disorder. All informant sources, parents, teachers, and the children themselves predicted early adulthood psychiatric disorders. Conduct symptoms at age 8 independently predicted substance abuse, antisocial personality, and psychotic disorders in early adulthood. Self-reported depressive symptoms, poor school performance, and living in a nonintact family had an independent predictive association with antisocial personality and depressive disorders. Parent-reported emotional symptoms and self-reported psychosomatic symptoms independently predicted anxiety disorders. About one third of those who had used services at age 8 had a psychiatric disorder in early adulthood. Among service users, conduct and hyperkinetic symptoms predicted psychiatric disorders in early adulthood. CONCLUSIONS: Efforts to prevent early adult psychiatric disturbance already present in childhood are emphasized. Active screening to detect children in need of early interventions in childhood to prevent negative development in early adulthood is justified.

Adolescent↗

Clinical leadership in health care: a position statement.

PURPOSE: This paper aims to briefly review leadership within the contemporary UK National Health Services (NHS) including Department of Health and Royal College of Nursing (RCN) initiatives. DESIGN/METHODOLOGY/APPROACH: It is argued that the concept of clinical leadership is a viable and important one, and is theoretically consistent with the contemporary social psychological literature on the importance of "local" leadership to effective organizational functioning. Field theory proposes that local influences (e.g. local management) on attitudes and behaviour will to a large extent mediate the impact of the organization (e.g. organisational structure and values) on (in this instance) health care delivery. FINDINGS: The reality of clinical leadership must involve a judicious blend effective management in the conventional sense with skill in transformational change in order to make real difference to the care delivery process. PRACTICAL IMPLICATIONS: For leadership initiatives to become truly culturally embedded into the "way we do things around here", they require more than just individual training and development. ORIGINALITY/VALUE: A view is offered for the practical interpretation of the clinical leadership concept in relationship terms. This will involve management of the relationship between health care professionals, between health care professionals and the "organizations" to which they are accountable and between health care professionals and service users.

Delivery of Health Care↗

What is the impact on individual health of services in general practice settings which offer welfare benefits advice?

Welfare benefits advice services are increasingly being provided on primary care premises. It is assumed that the relief of financial deprivation will also relieve ill health, although there is only limited evidence to support this. This paper reports the findings of a study designed to measure changes in individual health associated with income increase as a result of such advice. It was a longitudinal observational study of advice to service users, comparing the health of those whose income increased with that of those whose income did not, using the SF-36 as an outcome measure. The study took place in 2000 and 2001 in seven sites across England, and 345 people were interviewed at base line, 245 after 6 months and 201 after 12 months. Subjects were generally in the second half of life, with one or more chronic conditions. Those who increased their income (the Income Increase group) had significantly better outcomes in mental health and emotional role functioning at 12 months than those with no income increase. There were no other significant differences between groups at 12 months, and none at 6 months. However, if all those who dropped out of the study between 6 and 12 months are excluded, then the same changes observable at 12 months are also recorded at 6 months. Although improvements in health associated with income increase are modest, they make a significant contribution to patients' quality of life. Welfare benefits advice has a role to play as part of holistic care for low-income patients with chronic conditions.

Adolescent↗

The effect of involvement in participatory research on parent researchers in a Sure Start programme.

Involving service users, patients and members of local communities in health and social care research is becoming increasingly common. However, surprisingly little research has been carried out to examine the experiences of such lay researchers. This paper presents the findings of a study to investigate the experiences of a group of parent researchers involved in a community survey within a UK Sure Start programme. The survey was undertaken to provide insight into the early impact of the programme and inform Sure Start programme expansion. Researchers were recruited from the local community and were given an accredited training programme, before working on the development of the research itself. They took a lead role in the development, data collection, analysis and report writing phases of the survey and have been actively involved with the dissemination of findings. In order to gain insight into the experiences of the lay researchers involved in this work, three separate methods were used to collect data: questionnaires before and after the study, a focus group at the end of the data collection phase and by analysis of personal diaries kept by the parent researchers. Findings reported include lay researchers responses to the accredited training programme, the development of new skills and understanding, access and the conduct of interviews and the impact of the work both for Sure Start and the researchers themselves. Some of the strengths and difficulties of participatory research are discussed and comment made on the extent to which lay involvement impacted on the conduct of the survey.

Adult↗

Nursing and empowerment: concepts and strategies.

This paper argues that although there has been an increasing use of the term 'empowerment' in the nursing literature, the word is sometimes employed uncritically and in inappropriate contexts. The origins of the expression in community development work are noted, in an effort to set the activity of empowerment in its political context and to discuss the implications of this for the relative power of health professionals and service users. A distinction is drawn between the meaning of the term at the individual and the community level and an outline strategy is discussed for nurses who may wish to think through what empowering patients or clients will entail.

Authoritarianism↗

The construction and development of health professions: where will it end?

AIM: The aim of this paper is to evaluate the construction and development of professional health work as it has occurred over the past 15 years in the UK and present an informed, speculative analysis of present and future health care work. BACKGROUND: Since the early 1990s, there has been a strong political imperative in the United Kingdom (UK) to develop existing roles in nursing and the allied health professions, blurring professional boundaries and emphasizing patient/client-centred care delivery. This has already led to major changes in professional work patterns and the privileging of interprofessional work. Many of these changes have been shaped and determined by cultural and economic considerations. DISCUSSION: The socio-political context for the major changes in the roles of non-medical professionals in the UK is explored to demonstrate both consistency and contradictions with postmodern, consumerist values. The theoretical concepts that underpin professional formation and enable professionalization are examined in relation to present health service drivers for interprofessional work and the development of advanced practice roles, noting similarities and differences in aspirations. CONCLUSION: While professionalization and role development appear to have benefited both professions and service users in the short-term, their adoption and institutionalization by policymakers are influencing its direction in ways which both may ultimately find troublesome.

Delivery of Health Care, Integrated↗

Nursing attitudes towards acute mental health care: development of a measurement tool.

AIM: This paper reports the development, piloting and validation of a tool to measure attitudes for use with nursing staff working in acute mental health care units. BACKGROUND: The quality of care provided for service users in acute mental health care has come under both scrutiny and severe criticism. The attitudes of staff working in these environments have been cited as a contributory factor in poor care. No measure of attitudes specific to acute mental health has been reported. METHODS: A 64-question measure was constructed and distributed to a sample of qualified and unqualified nurses drawn from seven mental health care units in the North of England. Exploratory factor analysis and a number of other statistical tests were performed to validate the questionnaire. RESULTS: Preliminary analysis reduced the original 64 questions to 37. Five components were retained, accounting for 42% of the variance, and the five rotated factors were identified. The resultant 'Attitudes Towards Acute Mental Health Scale' (ATAMHS) achieved good internal reliability, with a Cronbach's alpha of 0.72. CONCLUSION: The construction and validation of the ATAMHS measure will enable improved understanding of the attitudes of nursing staff working in acute mental health care settings to occur. This measure is available for use in a clinical area of nursing in which attitude change is of fundamental importance for future development of care.

Acute Disease↗

Nurse prescribers: who are they and how do they perceive their role?

AIMS: This paper reports a study to elicit background data from recently qualified nurse prescribers and explore aspects of their work. BACKGROUND: Nurse prescribing has been introduced quite recently in the United Kingdom. Although a certain amount of information is available about the characteristics of nurse prescribers, relatively little is known about their professional backgrounds, their reasons for choosing to become nurse prescribers and their perceptions of their emerging role. More information is needed to inform the selection, education and support of nurse prescribers. METHOD: All nurses who undertook a nurse prescribing course in one university in the West Midlands during 2003-2004 were invited to participate in the study. A 40-item questionnaire was used to gather data on demographics, expectations of nurse prescribing, personal and professional development and perceived education needs. FINDINGS: Respondents considered that, despite initial problems, the nurse prescribing initiative would ultimately prove to be a cornerstone of improved service delivery for service users. The majority of nurses were already heavily involved in prescribing 'by proxy' and the course merely formalized what they were currently doing. Potentially, prescribing could advance the professional development of nurses, improve communication between professionals and patients, and make the experience of patients more beneficial. However, some concerns were expressed about how supportive the current climate in health care could be, given the multiple demands on time and energy required by so many other innovations. CONCLUSIONS: Respondents appeared balanced in their perceptions of this innovation and what it could realistically achieve. They were not indifferent to the many short and long-term problems that need to be resolved before it can be claimed to have become embedded in practice. The success of non-medical prescribing may depend on organizational support, coupled with a robust continuing professional development strategy for all nurse prescribers.

Adult↗

Involvement of older people in care, service and policy planning.

In line with other helping professions nursing has moved from traditional views of technical expertise as the prime shaper of health care, to a more equal relationship with service users and patients which respects their expertise, knowledge, goals and choices. This philosophy has underpinned the movement to involve older people in care, policy and planning activities. The literature review presented in this paper highlights the growing literature on this subject with respect to older people and maps the key issues and debates for nursing.

Aged↗

Transference, counter-transference and repetition: some implications for nursing practice.

AIMS: This discussion paper offers an introductory text for nurses and explores the psychoanalytic ideas of transference, counter-transference and repetition compulsion. Disguised case vignettes provide illustrations of the ideas as they might apply to nursing, including professional practice and occupational choice. BACKGROUND: The literature suggests that transference can be a source of creativity as well as destructiveness and influence important communications with oneself and others including the choice of nursing and other health professions as an occupation. Recognizing possibilities of transference, counter-transference along with repetitive patterns of behaviours, can help nurses of all specialities to address situations constructively by responding thoughtfully and appropriately. CONCLUSION: This discussion concludes with the suggestions that we know little about the motivational factors underlying nursing as an occupational preference; moreover, nursing does not have a culture of personal therapy. As such nurses are denied opportunities to understand the possible reasons underlying their occupational choice or gain experiential knowledge of interpersonal dynamics occurring between patients and colleagues. RELEVANCE TO CLINICAL PRACTICE: Transference and counter-transference are thought to have some bearing on all relationships. Forming a natural part of the way human beings relate to each other, transference and counter-transference can bring about sincere human interest, caring and concern. However, there is also potential for disagreements. Recognizing the possible origins of relational difficulties can offer opportunities for professional development to nurses along with the benefits for health service users.

Nursing↗

An evaluation of hospital-based specialized staffed housing for people with seriously challenging behaviours.

Resident and staff activity was observed in two hospital-based staffed houses for adults with severe or profound mental handicap, and seriously challenging behaviours. The results indicated that: (1) staffing resources were inefficiently deployed, leading to low levels of support being provided to service users; (2) staff attention was inequitably distributed across users, individuals showing the highest levels of seriously challenging behaviours received disproportionately more staff attention; (3) users spent little of the time they were observed engaged in constructive activities. Comparisons with data collected previously on four of the users in institutional settings indicated that: (4) no overall changes occurred in either user participation in constructive activities or (5) duration of challenging behaviours; and (6) overall, more staff contact was provided in the specialized housing projects compared to previous institutional settings. The results are discussed in terms of the determinants of quality in residential provision for people with seriously challenging behaviour.

Activities of Daily Living↗

Depot neuroleptic usage in adults with learning disabilities.

Most previous surveys of depot neuroleptic usage have monitored the consumption of oral psychoactive medications by heterogeneous mental handicap hospital populations. The present study assessed the prevalence, patient, practice and service delivery factors associated with depot neuroleptic usage in community learning disabilities services. The total of 79 adult subjects receiving depot neuroleptics roughly represented 0-5% of local service users. Several significant differences emerged between the factors associated with usage in the 61 (77%) subjects with psychotic disorders and 18 (23%) other subjects. Fitting backward elimination regression models accounted for 67-75% of the depot dosage variance. Comparison of these results with data from previous depot research studies suggested several methodological, clinical, ethical and research issues for future consideration.

Adult↗

Assessing the reading comprehension of adults with learning disabilities.

BACKGROUND: This study's aim was to begin the process of measuring the reading comprehension of adults with mild and borderline learning disabilities, in order to generate information to help clinicians and other professionals to make written material for adults with learning disabilities more comprehensible. METHODS: The Test for the Reception of Grammar (TROG), with items presented visually rather than orally, and the Reading Comprehension sub-test of the Wechsler Objective Reading Dimensions (WORD) battery were given to 24 service-users of a metropolitan community learning disability team who had an estimated IQ in the range 50-79. RESULTS & CONCLUSIONS: These tests were demonstrated to have satisfactory split-half reliability and convergent validity with this population, supporting both their use in this study and in clinical work. Data are presented concerning the distribution across the sample of reading-ages and the comprehension of written grammatical constructions. These data should be useful to those who are preparing written material for adults with learning disabilities.

Adolescent↗

Economies with 'the truth': professionals' narratives about lying and deception in mental health practice.

In psychiatric and psychotherapeutic literature, the idea of clients lying is not one that is commonly voiced, and many therapeutic positions seem to discourage discussion of the issue. In practice, however, professionals do meet with people who they feel are not being 'truthful', and this study sought to examine the narratives that a group of colleagues provided about the resulting conflicts and dilemmas. Through the use of unstructured interviews, I invited mental health practitioners to discuss their experiences of situations where they felt clients were lying to them. From an analysis of these research conversations I propose that, in a psychiatric context, lying and secrecy often occur as response to an experience of powerlessness by service-users. I also suggest that the issue of clients lying requires more open discussion amongst practitioners, in order to explore differences in power and perspective between professionals and clients.

Attitude of Health Personnel↗