The role of psychiatric diagnosis in satisfaction with primary care: data from the department of veterans affairs

BACKGROUND: Although patient satisfaction is widely used as a quality indicator, most such measures do not account for patient subgroups such as those with psychiatric illness. There is also very little data on satisfaction of psychiatric patients with their medical care. OBJECTIVE: The objective of this study was to assess the role of psychiatric illness in satisfaction with outpatient primary care services in the Department of Veterans Affairs (VA). METHOD: Data from the VA Customer Feedback Survey (n = 50,532) were merged with administrative data to determine diagnoses and other characteristics. Satisfaction ratings were compared across psychiatric diagnoses and across various aspects of satisfaction with care. RESULTS: After controlling for patient characteristics (eg, gender, age, disability, acute vs. routine visit) and subjective health, patients with schizophrenia, posttraumatic stress disorder, drug abuse, depression, and other psychiatric disorders reported significantly lower satisfaction with their outpatient primary care. Dissatisfaction was particularly reported for access to care and overall coordination of care. CONCLUSIONS: Despite VA characteristics that might be thought to improve satisfaction (eg, easier access to specialty mental health services as a result of the integrated VA system), patients with psychiatric disorders are significantly less satisfied than patients without such disorders. Possible explanations include both lower technical quality of care and poorer interpersonal communication between providers and patients with mental illness, including the negative effects of stigma. These findings highlight the need for satisfaction ratings to be case-mix-adjusted, including the incorporation of health and mental health diagnoses, and the need for further research that elucidates the reasons behind lower satisfaction ratings.     

The need for psychiatric nursing: towards a multidimensional theory of caring

Contemporary developments in health care have encouraged a review of the professional status of psychiatric nursing. Although research has documented psychiatric nursing activity, little study has been made of the 'need' for psychiatric nursing within a multidisciplinary service. Employing adapted grounded theory methodology, substantive theory was developed concerning the expressed need for psychiatric nursing, by patients, their carers and mental health professionals. The study was based on six sites from England, Eire and Northern Ireland. The study found some consensus across both recipients and providers of mental health care, that the essential feature of nursing (the core category) involved a complex of relationships: 'knowing you, knowing me'. Within that complex, nurses either elected, or were required, to move--or 'toggle'--between three discrete domains of relating: the Ordinary Me (OM); the Pseudo-ordinary or Engineered Me (POEM); and the Professional Me (PM). Four internal dimensions involving the nurses' depth of knowing, power, use of time and use of translation distinguished these domains. The emergent theory extends current awareness of the importance of interpersonal relations in nursing. To what extent current health care policy, which emphasizes the promotion of alternative roles for nurses, will challenge this essential focus remains unclear.     

Quality of life for long-stay patients of psychiatric hospitals: a literature study

The aim of this literature review is to provide an answer to the following questions: (1) What is known about the quality of life and quality of care for long‐stay psychiatric patients? (2) What does literature say about possible contributions that health‐care professionals may make to the quality of life for this target group? We conducted an open literature search across national and international databases, and added relevant literature by using cross‐references. The quality of life and quality of care for long‐stay psychiatric patients has been the subject of research on a limited scale only. Publications in this field provide a picture of patients with wishes and requirements that are generally basic and modest in nature. They also show that patients greatly value good relations with their care providers. This literature review shows that little is known about the quality of life of long‐stay psychiatric patients and this review also shows that the relational aspects of care provide an eminent opportunity for care providers to contribute to the quality of life of their patients. Long‐stay patients need care providers who are capable of developing and maintaining a caring relationship of the highest quality that will endure for many years. In their daily work, nurses have good opportunities to develop and maintain meaningful and reciprocal relationships with severely ill people, but this is a task that makes great demands on nurses in terms of both knowledge and interhuman skills. These skills should be given special attention both in nurse education and by supervisors.     

Patterns of care in patients utilizing both primary health care and psychiatric care in a Swedish health district

Patterns of care in all patients (N = 546) establishing contact with both primary health care and psychiatric care were studied during 1984 (N = 252) and 1986 (N = 294) in a Swedish health district. Utilization of primary health care was not affected by the sectorization of the psychiatric care organization, while there was a significant increase in utilization of outpatient psychiatric care. Patients with a higher number of visits in outpatient psychiatric care had a lower number of visits in primary health care. The utilization of care was unevenly distributed in the sample; 25% of the patients accounted for almost 60% of the visits in both care organizations. The mental health problems were identified in primary health care in 40% of the patients. This group of patients seemed to be defined as belonging neither to specialized psychiatric care nor to the general practitioner level of primary health care.     

What are psychiatric nurses needed for? Developing a theory of essential nursing practice

Contemporary developments in health care have encouraged a review of the professional status of psychiatric nursing. However, little study has been made, to date, of the discrete 'need' for psychiatric nursing within a multidisciplinary service. Employing an adapted grounded theory methodology, substantive theory was developed concerning the expressed need for psychiatric nursing, by patients, their carers and mental health professionals, based on six sites from England, Eire and Northern Ireland. The study found some consensus across both recipients and providers of mental health care, that the essential feature of nursing (the core category) involved a complex of relationships: 'knowing you--knowing me'. Within that complex, nurses either elected, or were required, to move--or 'toggle'--between three discrete domains of relating: the Ordinary Me (OM); the Pseudo-ordinary or Engineered Me (POEM); and the Professional Me (PM). Four internal dimensions involving the nurses' depth of knowing, power, use of time and use of translation, distinguished these domains. The emergent theory is discussed within the context of the emergent growth in user (consumer) influence and health care technology.     

Transition of Nurse Practitioner Faculty Practice and Student Clinicals to Telehealth: Response to the COVID-19 Pandemic

The COVID-19 pandemic forced the US health care system to evaluate alternative care delivery strategies to reduce the risk of coronavirus transmission to patients and health care providers. Telehealth modalities are a safe and effective alternative to face-to-face visits for primary and psychiatric care. Federal policy makers approved changes to telehealth reimbursement coverage and allowed flexibility of location for patients and providers. This article describes the transition of patient visits to telehealth by nurse practitioner faculty at an academic medical center to maintain continuity of care of underserved patient populations. This pivot facilitated resumption of clinical learning experiences for nurse practitioner students.     

Nurse Practitioners: Integrating Mental Health in Pediatric Primary Care

There is increasing recognition of the critical need for pediatric primary care providers to attend to the developmental, behavioral, and mental health needs of children and adolescents in their practices. Children and families have difficulty accessing psychiatric care because of scarce psychiatric specialists, stigma associated with referrals, and service fragmentation. The use of pediatric and family nurse practitioners with expertise in developmental, behavioral, and mental health care to provide this care within the pediatric health care home is a solution to address the growing need for integration of accessible, quality mental health services in primary care.     

Trauma Screening Is More Common When Primary Care Patients Trust Providers

Trauma exposure and posttraumatic stress disorder can have a considerable impact on psychiatric health, physical health, and health behaviors. This study assessed how often screening occurs among primary care patients and which patients are more likely to be screened. Primary care patients (N = 316) completed a survey with a trauma screen and measures of trust toward their providers. Trust improved the likelihood of screening in unadjusted (odds ratio, 1.06; 95% confidence interval, 1.01-1.12) and in adjusted models (odds ratio, 1.10; 95% confidence interval, 1.03-1.16). Screenings occurred more commonly among patients with mental health issues and who had higher trust in their provider. Implications are discussed.     

The challenge of providing continuity in the care of a disabled child: Smith-Lemli-Opitz syndrome

The health of a disabled child can be adversely affected if parents and health care providers are not informed regarding the need for ongoing care and consultation. This case illustrates the ways in which failure to obtain appropriate consultation and breakdown in communication between parents, health care providers, and community agencies negatively impacted the health of a young child with Smith-Lemli-Opitz Syndrome (SLOS). Although the disorder was detected in the child, information regarding treatment was not communicated to those caring for the child, resulting in serious and potentially life-threatening consequences. In this case study, we review the pathophysiology of SLOS, the positive impact of making use of expert consultation, and the complexities of navigating multiple systems when advocating for a child with a serious developmental disorder. The role of nursing in facilitating collaboration among families, members of the health care team, and advocacy agencies, particularly in children with complex medical and psychiatric difficulties, is highlighted.     

Psychiatric nursing care experiences of immigrant patients: A Focused ethnographic study

This study aimed to describe the psychiatric nursing care experiences of immigrant patients. The incidence of mental health problems is higher and the use of mental health services is lower among immigrants, especially refugees, compared with the majority of the population. The study uses a qualitative research approach, with an emphasis on focused ethnography research methods. The participants were immigrant patients (N = 14) residing in adult psychiatric wards of certain hospitals (N = 3) selected for the study. A majority of the participants were refugees or asylum seekers. A total of 21 in‐depth interviews were conducted. The experiences of these immigrant patients, both in their home countries and in their country of residence, had had an adverse effect on their mental health, with past traumatic experiences being the most central factor. Their symptoms included depression, anxiety, somatization, and psychosis. The findings show that the categories of factors that helped promote recovery among immigrant patients were nursing, medical treatment, care environment, and the patients' own methods. Based on the findings, a systematic evaluation of traumatic experiences is recommended for immigrants from countries with a history of war and/or political violence. Healthcare providers should also consider the importance of cultural desire in psychiatric nursing for the recovery of patients.     

The meaning of caring for patients on a long-term psychiatric ward as narrated by formal care providers

Seventeen care providers were interviewed about their caring experiences on a hospital psychiatric ward. The interviews focused on the meaning of their work, including the care they provide and the nature of the patient as a person. The study was guided by a phenomenological hermeneutic perspective inspired by Ricoeur (1976). The analysis focused on context and form. Three themes illuminate the meaning of care provided. These themes are as follows; being in the midst of human storage, moving towards a human care of relations, and struggling with 'the old' and 'the new'. Experiencing work as being in the midst of a human storage reflects the historical and human situation of warehousing psychiatric patients. The care providers are experiencing a shift in their view of the patient and the meaning of their work, towards a more human care of relations. For these care providers, there is a struggle between the past, the present and the future. This struggle between 'the old' and 'the new' conveys a struggle between doing as a nurse, which dominates the past, and relating, which is, or needs to be, the current and future focus in psychiatric care. The shift in view distinguished itself by the care providers viewing the patient as being vulnerable and having problems with relations. The results have been interpreted and discussed in the light of a previously published interview study with the patients, carried out at the same time on the same ward. Attending to ingrained attitudes of the past and their influence on new approaches to care is essential to understanding not only changes in ways of doing nursing tasks, but also ways of relating.     

Practice patterns and potential solutions to the shortage of providers of older adult mental health services

Little is known about the contribution of advanced practice nurses (APNs) to the mental health care of older adults. This study describes mental health services to older adults by APNs compared with primary care physicians, psychiatrists, psychologists, and social workers. The study uses a retrospective, cross-sectional design with a 5% national sample of 1999 Medicare outpatient claims. Bivariate statistics and multinomial logit models were used to determine differences among these mental health providers. A small proportion of the nationally available providers (10.4%) submitted claims for mental health services rendered to older adults. APNs, psychiatrists, and primary care physicians care for a disproportionate number of rural and poor older adults with complex medical/psychiatric needs compared with psychiatrists, psychologists, and social workers. APNs seem to be an untapped resource for providing mental health services to older adults. Health policy reform is needed to remove barriers to meet mental health care needs.     

Help-seeking behaviors by Korean immigrants for depression

Underutilization of mental health services by Asian immigrants has been an ongoing concern for those attempting to provide accessible care for people suffering from mental illness. The author investigated Korean immigrants' help-seeking behaviors for depression to understand their underutilization of mental health services. The study involved 6 focus group discussions and 24 in-depth interviews with 70 Korean immigrants in New York City. Prolonged care within family and traditional Asian practices led to a delay in seeking mental health services, keeping many Korean immigrants with depression out of the delivery system. The lack of interface between formal service providers and psychiatric service providers also caused delayed treatment. This study suggests the need for a comprehensive care model based on community education, linking mental health care with other services, and cultural brokering, as ways to connect population needs with mental health service delivery.     

Patient-Centered Homes and Integrated Behavioral Health Care: Reclaiming the Role of “Consultant” for Psychiatric-Mental Health Nurse Practitioner

The notion of patient-centered care has long been linked with nursing practice since Florence Nightingale. The discipline of nursing is focused on the holistic care of individuals, families, and communities in times of sickness and/or health. However, in psychiatric-mental health nursing, the concepts of mental health and psychiatric illness still remain marginalized in our health care delivery systems, as well as in nursing education, knowledge development, and practice. Even with the concept of patient-centered homes, acute and primary care providers are reluctant to embrace care of those with psychiatric illness in their respective settings. Psychiatric illness was and continues to be in the shadows, hidden and often ignored by the larger community as well as by health care providers. This paper describes a Health Resources Services Administration (HRSA) Advanced Nursing Education (ANE) training grant's objective of reintegrating psychiatric-mental health practice into ALL health care delivery systems using the concept of patient-centered nursing care as a foundation for, and promotion of, the Psychiatric-Mental Health Nurse Practitioner (PMH-NP) as the “navigator” for not only the patients and their families, but also for their acute and primary care colleagues using an Interprofessional Education Model. The major barriers and lessons learned from this project as well as the need for psychiatric-mental health nurses to reclaim their role as a consultant/liaison in acute, primary, and long-term care settings will be discussed. The PMHNP as a consultant/liaison is being revitalized as an innovative advanced practice nursing health care model in North Carolina.     

Multiprovider and Patient Perspectives on Conveying Diagnostic Imaging Investigation Results in a South African Public Health Care System

IntroductionThis study explored interaction processes in conveying messages about the results of diagnostic imaging investigations in a public hospital complex in South Africa from the perspective of health care providers and patients.MethodsThe study was part of a qualitative inquiry into the interaction and communication processes relating to diagnostic imaging investigations in the public health care system. Data collection included individual interviews with 24 patients and 62 health care providers (ie, medical practitioners, specialists, radiologists, registrars, radiographers, and nurses). In addition, 12 focus group interviews were conducted with health care providers. The transcribed data were coded and analysed to identify categories and themes.ResultsThree main themes emerged from the study. The first theme deals with the medical territory, specifically who should interpret and convey the diagnostic results to the patient. The second theme highlights the role of radiographers and nurses in communicating parts of the diagnostic results. The last theme focuses on patient experience, interpretation, and comprehension in the provider-patient communication process.ConclusionsThe findings provide a multidimensional view about the disclosure of imaging results to patients by medical and nonmedical health care providers. Further research is needed on the role of nonmedical providers in the context of ethical and moral obligation toward patients and the professional restrictions inherent in their scope of practice.     

Hospital–community interface: A qualitative study on patients with cancer and health care providers' experiences

BackgroundPatients with cancer must deal with complex and fragmented healthcare systems in addition to coping with the burden of their illness. To improve oncology treatment along the care continuum, the barriers and facilitators for streamlined oncologic care need to be better understood.PurposeThis study sought to gain insight into the hospital–community interface from the point of view of patients with cancer, their families, and health care providers on both sides of the interface i.e., the community and hospital settings.Methods and sampleThe sample comprised 37 cancer patients, their family members, and 40 multidisciplinary health care providers. Twelve participants were interviewed individually and 65 took part in 10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative analyses were used.ResultsTwo major concepts emerged: “ambivalence and confusion” and “overcoming healthcare system barriers.” Ambiguity was expressed regarding the roles of health care providers in the community and in the hospital. We identified three main strategies by which these patients and their families overcame barriers within the system: patients and families became their own case managers; patients and health care providers used informal routes of communication; and nurse specialists played a significant role in managing care.ConclusionsThe heavy reliance on informal routes of communication and integration by patients and providers emphasizes the urgent need for change in order to improve coordinating mechanisms for hospital–community oncologic care.     

THE CHALLENGE OF PROVIDING CONTINUITY IN THE CARE OF A DISABLED CHILD: SMITH-LEMLI-OPITZ SYNDROME

The health of a disabled child can be adversely affected if parents and health care providers are not informed regarding the need for ongoing care and consultation. This case illustrates the ways in which failure to obtain appropriate consultation and breakdown in communication between parents, health care providers, and community agencies negatively impacted the health of a young child with Smith-Lemli-Opitz Syndrome (SLOS). Although the disorder was detected in the child, information regarding treatment was not communicated to those caring for the child, resulting in serious and potentially life-threatening consequences. In this case study, we review the pathophysiology of SLOS, the positive impact of making use of expert consultation, and the complexities of navigating multiple systems when advocating for a child with a serious developmental disorder. The role of nursing in facilitating collaboration among families, members of the health care team, and advocacy agencies, particularly in children with complex medical and psychiatric difficulties, is highlighted.     

Nurse‐Managed Free Clinic Fosters Care Connection for Homeless Population

The goal of this article is to demystify the process that healthcare providers must follow when working with homeless patients who sustain injuries or exhibit illnesses that necessitate rehabilitation care. Observations made over a period of more than 12 years at an inner‐city medical/psychiatric nurse‐managed free clinic that delivers cutting‐edge services and educates multidisciplinary students to care for disenfranchised populations led the author to several conclusions: homeless people frequently lose their identity as individuals when facing healthcare providers; previous negative perceptions of homelessness can turn positive when care providers meet these patients on a person‐to‐person level; the concept of health and rehabilitation must be clearly understood in the same way by both providers and patients for nursing goals to be realistic and achievable; and a collaborative relationship must be formed between nurses and patients.