Implementing a structured psychosocial interventions group programme for people with bipolar disorder

It has been reported that, at any time, over half of the people with bipolar disorder are receiving no active treatment. Despite the availability of effective medications and psychotherapies, research concludes that the care of bipolar disorder in everyday practice is often deficient. Evidence base reports the effectiveness of psychosocial interventions using many of the same ideas as the recovery approach; both attempt to place clients at the heart of service delivery. This paper reports on the development and implementation of three pilot group programmes for service users with bipolar disorder, in a community clinical setting in South East England. The group programme design and development was based upon the evidence-based psychosocial interventions advocated in national clinical guidelines and research literature. The programme incorporated the key effective psychosocial interventions and self-management mechanisms within its 12 sessions spanning over 3 months, followed by three booster sessions in 6 months' time. Twenty-three service users have to date completed the programme. Participant feedback will be discussed and reported to inform further development and research implications of such innovative evidence-based interventions for service users with bipolar disorder.     

Preparation for alcohol detoxification group programme. Service users’ evaluation of individual sessions

There is limited evidence to guide clinicians on how to prepare alcohol-dependent clients for detoxification. This paper briefly reports the evaluation of the Preparation for Alcohol Detoxification group programme sessions by service users. Methods: Clients attending the programme provided feedback using a specially developed form containing closed and free text questions. Results: One hundred and thirty three forms were analysed out of 166 received. Completion rate per session varied from 46 to 100%. The majority of clients were positive or partly positive for all sessions. Clients felt welcome to participate in all sessions. For the sessions “understanding addiction” and “relapse prevention” clients were rather neutral, indicating a need to change session content or focus. Conclusion: Clients felt able to participate actively despite the structured nature of the sessions. The positive response might be related to the therapeutic approach taken by group facilitators, inviting clients to engage in active exploration of their difficulties and practise of potential solutions, achieving a balance between didactic and experiential style.     

Staff and client perspectives of the Open Borders programme for people with borderline personality disorder

In recent years, there has been a move away from the medical model of care for people with borderline personality disorder, as hospital admission comes with a number of risks and potential adverse consequences. Although long‐term outpatient‐based therapy is successful, this may not be an option for those whose condition is in need of stabilisation. Brief admission for crisis intervention has been successful and is now widely used; however, research that examines both the staff and clients’ perceptions of a dedicated programme is lacking. Open Borders is a residential recovery‐oriented programme that provides brief admission, respite, and phone coaching for people with borderline personality disorder who are heavy users of the public mental health system. In this paper, the authors report the perspectives of clients and staff of the Open Borders programme obtained through semi‐structured interviews. Thematic analysis of client and staff perspectives identified four common themes: ‘Benefits of the programme’, ‘Enhanced client outcomes’, ‘Impact of the physical environment’, and ‘Ways of enhancing service delivery’. In addition, analysis of the staff perspectives included the theme ‘Emotional impact on staff’. Benefits of the programme included the small supportive team approach, flexibility of the staff to spend time with the clients to tailor care, and the relaxed, welcoming environment. Enhanced client outcomes included a reduction in self‐harming and hospitalization and an increase in self‐efficacy. These results support the move away from the medical model and the empowerment of clients to self‐manage their symptoms while fostering hope and self‐determination.     

Involving clients in programme evaluation and research: a new methodology for occupational therapy

Eliciting client satisfaction with services has become common in mental health settings and in the planning of service delivery systems. It is also compatible with the client-centred practice of occupational therapy. The traditional approach to collecting satisfaction information involves staff interviewing clients using questionnaires developed by staff. However, there is often a lack of variability in responses and the vast majority of clients report being satisfied. A review of the literature reveals that these favourable reports may be a result of social desirability and of clients being interviewed by treatment providers who have the power to give or withhold care. This paper reviews the relationship between occupational therapy and client involvement, examines the rationale for involving clients in programme evaluation and research, reviews the limitations with traditional methods of collecting information about client satisfaction, and discusses how clients are involved in evaluation and research in today's mental health care setting.     

Patient involvement in education for enhanced quality of care

Government policies in the UK are promoting health care practitioners working in partnership with patients and clients as an important constituent of quality in health care delivery. However, for practitioners to work in this way requires experience of such partnerships in the educational preparation. The involvement of patients and clients (i.e. service users) and their carers in the curriculum has been encouraged and supported in England since the early 1990s. From 1998, the comprehensive involvement in all phases of programme provision has been a requirement, ensuring that service users have a real 'voice' in influencing the direction of programmes. Examples of good practice are provided, demonstrating a range of approaches in the different stages of the educational process. Issues to be considered for successful implementation are included. Benefits to education and patient/client care are identified on the basis of literature and recent experience. They are strongly associated with enhanced quality of care. The article argues for a need to continue to broaden implementation for the major benefits of influencing the attitudes and approaches of students, and empowering users, with the end result of enhancing the quality of care. A strategic approach is needed to make user involvement an effective and workable reality. The need for systematic evaluation of the outcomes and for publications is highlighted. The principle of service user involvement in educational preparation is deemed to be equally relevant in other countries.     

User involvement in mental health branch education: client review presentations

This paper will present the work of users, students and lecturers involved in the delivery of Mental Health pre-registration education, focusing on client assessment. Users from local mental health representative organizations, attend a series of college-based sessions to evaluate student's client review presentations, in which individual students explicitly and critically reflect upon a mental health assessment of a client in which they have participated. The user contributions are intended to raise student's awareness of client-centred perspectives, particularly in terms of the various possible interpretations that may be attributed to assessment data gathered about the client. The sessions seek to develop a learning approach, which will develop and consolidate a partnership in curriculum delivery between mental health service users and nursing education. This method of working has been evaluated by a previous study, and indicates that this method has an important influence on student's approaches to identifying clients needs and subsequent care delivery. This paper will focus on the organizational pre-requisites that are desirable, to implement this method of teaching and learning, including philosophical issues, contract arrangements, classroom activities, supervision, consideration of ethical dilemmas and reflective outcomes.     

Client and parent feedback on a Youth Mental Health Service: The importance of family inclusive practice and working with client preferences

In mental health settings, feedback from clients and carers is central to service evaluation, development and delivery. Increasingly, client and carer feedback is considered an integral part of service planning, and recognized as a critical element of the provision of recovery oriented service. This paper outlines the findings of a qualitative evaluation of a Youth Mental Health (YMH) service from the perspective of discharged clients and their parents. The service researcher conducted telephone interviews with 39 parents of discharged clients, and 17 young people themselves. Participants reported positive or mixed experiences with the service. In addition to more generic positive statements about the service, analysis identified two key themes: the importance of ‘family inclusive practice’ and the importance of ‘working with client preferences’. Young people and their parents want to be actively engaged in treatment and have their treatment preferences considered in treatment planning. Participants expressed the importance of “a good fit” between the client and the worker in terms of the clinician's gender, personality and treatment style/modality. While for some participants these themes were raised in the context of service strengths, others identified them as limitations or opportunities for service improvement. The extent to which clients and their parents felt engaged and heard by their allocated clinician is critical to their satisfaction or dissatisfaction with the service, depending on their unique experience. As an outcome of this evaluation, a range of service improvement strategies have been recommended.     

Dependent substance misuse in adolescence: a picture beginning to emerge?

With the emergence, in some areas, of services for young substance misusers, problematic and sometimes dependent young people are presenting themselves at these agencies. Numbers around the country are difficult to quantify, but where specialist advice is offered a number of clients who fit into these categories will be seen. A picture of what makes a young person particularly vulnerable to substance misuse is beginning to emerge. With little guidance on what is effective treatment for this group, a clinic was set up to offer a service for substance users who were under 18 years of age. This paper focuses on the most dependent young people, a small proportion of the users of the service. A multi-disciplinary team with a holistic approach demonstrated that some young people could make significant improvements in many aspects of their lives, including their substance misuse.     

Evaluation of a low-threshold clinic for opiate-dependent drug users

This study reports on the development and outcome of a Low Threshold Clinic (LTC) for opiate-dependent drug users. The service originated as a nursing initiative within an inner city Drug Dependency Centre (DDC) and its rationale and treatment approach are explored in relation to the literature and local circumstances. Client baseline and outcome data were systematically gathered to assess service uptake and service efficacy in terms of client outcome. Data are presented for the first two years of operation during which a total of 59 clients entered the LTC. The sociodemographic characteristics and patterns of drug use among this group suggest the service was successful in targeting clients who previously failed to enter traditional treatment programmes despite initial referral to the DDC. Outcome data indicate a tendency for clients to inject less frequently, engage in less criminal activity and, by 12 months, to reduce their dose of prescribed methadone whilst attending the LTC. Tentative conclusions are drawn concerning the value of this service for 'hard-to-reach' drug users and those who may be at a precontemplation stage of change. Recommendations are made for a more comprehensive evaluative study that involves comparison with other treatment approaches.     

Reflect before you act: providing structure to the evaluation of rehabilitation programmes

Purpose: This paper is concerned with understanding and evaluating potentially diverse rehabilitation programmes. It helps evaluators and programme managers to focus attention on specific aspects of the rehabilitation process and select evaluation questions relevant to each.

Method: Distinction is made between the rehabilitation programme itself, the programme environment and the relationships between the two. For each of these areas, evaluation questions have been formulated. For services offered to individual clients, questions address whether the status of clients has improved, what interventions are offered and who benefit from them, the relationships between the service providers and the clients, and who may be involved in the rehabilitation process besides the client. To assess the programme environment, questions address the epidemiology of disability, the resources available to persons with disabilities, the inclusiveness of education and employment and a number of eco-social variables. Relationships between the programme and its environment concern the support of the community for the programme, the way the programme seeks to influence the community, the referral of clients to other services available in the community and the extent to which the programme is a learning organization.

Results: Lists of evaluation questions are presented from which the evaluator can select those most relevant to the programme to be evaluated. This provides a framework for the evaluation and for the information to be gathered. Rather than providing a blue print, this framework permits flexibility to adapt to the specific situation of the programme to be evaluated.

Conclusion: This paper presents a useful guideline that stimulates the thinking of those preparing for the evaluation of rehabilitation programmes.     

Dual diagnosis: co-existence of drug, alcohol and mental health problems

The Department of Health (DoH) published a set of good practice implementation guidelines on dual diagnosis in May 2002. This guidance suggests that in order to improve the prognosis for clients who have mental health problems and who drink or take drugs problematically, mental health and substance misuse services should adopt an integrated service model. There is a considerable amount of American-based research supporting this approach, but little evidence from the UK researchers demonstrating its application in the UK. This article offers an example of a service that has been developed in the city of Nottingham and argues that this client group will be served most effectively if mental health services support specialist dual-diagnosis resources. Integrated care pathways for this client group can be developed and led by specialist clinicians acting as consultants to mental health services (DoH, 2002a). This consultancy role within mental health services enhances the links needed between substance misuse and mental health services. As a result, specialist dual-diagnosis teams are best placed to increase positive prognoses for clients by ensuring evidence-based substance misuse skills are utilized and adapted by mental health teams to ensure fully integrated care coordination.     

Respiratory teaching of patients: how effective is it?

In order to evaluate the effectiveness of a structured respiratory teaching programme, clients with chronic obstructive pulmonary disease who were hospitalized in a 13-month period both prior to and following the implementation of the programme were compared on several parameters to assess changes in their ability to manage their disabilities. The study demonstrated that clients who participated in the teaching sessions had fewer hospital admissions, shorter lengths of hospital stay, and longer stays in the community. A sub-group of clients who were or had been in at-risk occupations was identified as representing the 'revolving door' client with shorter hospital and community stays. The teaching programme is described as well as specific elements that can be used for a shorter teaching experience to respond to time constraints when necessary.     

Dual diagnosis screening: preliminary findings on the comparison of 50 clients attending community mental health services and 50 clients attending community substance misuse services

While dual diagnosis research has often focussed on substance misuse disorders among mental health clients, relatively little is known about comparable rates of dual diagnosis in community mental health and substance misuse settings because of, inter alia, limitations and lack of consistency in screening. In the current study clinicians administered a brief screening tool, which detects problematic alcohol, drug use, psychosis and common mental health symptoms, to 50 substance misuse and 50 mental health treatment attenders. Sixty-four per cent of the total sample screened positive for dual diagnosis (positive for any psychiatric disorder and either a drug or alcohol problem). Highest rates were observed in the alcohol sample (92.3%), followed by the drug sample (87.5%), and lowest in the community mental health (CMHT) sample (38%). Current depression and social phobia were most prevalent in alcohol clients compared to psychosis, mania and suicidal ideation in CMHT clients. Around one-third of CMHT clients reported using drugs (mainly cannabis) and around a fifth reported problematic alcohol use. The study demonstrates the feasibility of incorporating a dual diagnosis screen into routine clinical practice. The screen can be used in both mental health and substance misuse treatment settings, which are evidently managing complex client caseloads.     

Nursing considerations for dual diagnosis in mental health

It is the intention of this literature review to present suggestions for nursing practice with reference to the care of the dually diagnosed. Nursing care of the dually diagnosed client is complex. Clinicians from both drug and alcohol services and mental health services have long recognized that neither service area provides adequate clinical care to those clients who have a dual diagnosis of substance abuse and mental illness. It is now > 10 years since a ground-breaking Australian study recognized this. To ascertain whether there has been improvement in the service management of clients who have a dual diagnosis, and to determine the best practice interventions in the area of mental health nursing, we undertook a review of the literature. The databases CINAHL, MEDLINE, PsycARTICLES and PsychINFO were searched and 185 articles met the inclusion criteria. From this review, it seems that gaps still remain in the provision of services and that mental health nurses might be best placed to provide integrated care to those clients who have a dual diagnosis and present to mental health services. This requires mental health nurses to have skills in substance use detection and knowledge of potential care implications for the client in the context of their substance use.     

Factors in care management affecting client outcomes in home care

The purpose of the present study was to identify which factors in care management affect client outcomes. We performed path analysis using care management processes as independent variables, and client outcomes measures as dependent variables. Client outcomes were measured by improvement in care items and Functional Independence Measure (FIM) scores in 170 clients, and client satisfaction in 97 clients. Improvement in care items was significantly related to the amount of service. Deterioration of the functional independence level was significantly related to the amount of service and lower implementation of monitoring. Higher implementation of evaluation raised client satisfaction. It is important for care managers to develop a care plan based on the necessary amount of service and to perform monitoring. A sufficient amount of service in the care plan and higher implementation of monitoring and evaluation are the three factors in care management affecting client outcomes.     

Evaluating a community nursing service: listening to the voices of clients with an intellectual disability and/or their proxies

The aim of this study was to evaluate a specialist nursing service programme for people with an intellectual disability residing in the community. It is important to correct the imbalance in the literature that has neglected the voices of the clients themselves or denied expression by their proxies. The aim of the study was to gain a better understanding of matters of importance for clients and their families and to involve them in the evaluation of a service that directly affects their care. Only three clients were able to participate; however, 17 parents (next of kin) agreed to be interviewed. In-depth interviews were audio-taped, transcribed and analysed relating to the questions asked and were checked against the domains of the nursing practice in the disability area: continuity of care, advanced nursing practice, education and credentialling, personal and professional attributes, primary health care, and normalization. The findings confirm the high regard in which the programme is held. Service evaluation is crucial in providing evidence for programme funders. The favourable outcome of this evaluation meant that the programme gained funding for another few years.     

An evaluation of a communication skills course for health visitor students

This paper presents part of the findings of an extensive empirical evaluation of a communication skills training programme for health visitor students. The programme was designed to develop the health visitors' ability to communicate with clients. A wide range of interpersonal skills were addressed and the training format involved skill analysis, roleplay practice and video-recorded feedback. The method of evaluation included an appraisal of the health visitors' social behaviour in a roleplay of a home-visit to a pregnant client. Data were collected, both before and following training, in an attempt to assess changes in trainee behaviour. The analysis took the form of a detailed frequency measurement of behavioural elements of health visitor performance, and a global rating of social competence by independent judges. Results of the analyses indicated that 14 out of the 20 behavioural variables changed in the desired direction. Thus, for example, following training the health visitors used significantly more open questions and verbal encouragers, and significantly fewer multiple questions and interruptions when communicating with the client. They were also rated significantly higher on the rating scale for social competence following training. These findings would seem to suggest that the training programme had a considerable degree of success. The findings are discussed in terms of the implications for development of health visitors' social skills, the need for more sophisticated measures of social behaviour and for the formulation of a model of competent professional practice in this area.     

An evaluation of a community aged care nurse practitioner service

Evaluation aims. An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team. Background. In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities. Design. An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken. Method. All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi‐structured interviews. Results. Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients’ physical and psychological symptom management, enhance clients’ quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision. Conclusions. Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting. Relevance to clinical practice. Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.