The effects of a transitional discharge model for psychiatric patients

This pilot randomized control trial was motivated by the discovery that many individuals with mental health problems are re-hospitalized within a year, with many being unable to fully adjust to community living. A solution was proposed in the form of an intervention called transitional discharge. The transitional discharge model included: (1) peer support, which is assistance from former patients who provide friendship, understanding and encouragement; and (2) overlap of inpatient and community staff in which the inpatient staff continue to work with the discharged patient until a working relationship is established with a community care provider. The overall aim of this study was to test the discharge model designed to assist patients discharged from acute admission wards to adjust to community living. This aim was tested through a number of related hypotheses, which suggest that, 5 months following discharge from an acute admission ward of a psychiatric hospital, individuals participating in a transitional discharge model: (1) report fewer symptoms; (2) report better levels of functioning; (3) have better quality of life; (4) are less likely to have been re-admitted to hospital. The study used a randomized experimental design with two conditions: experimental and usual treatment. In general, both the control and the experimental group demonstrated significant improvements in symptom severity and functional ability after 5 months. Usual treatment subjects in the control group were more than twice as likely to be re-admitted to hospital. This study needs to be replicated in Scotland with a larger sample and with a modified variation of the intervention called the Transitional Care Intervention.     

Coping with everyday reality: Mental health professionals’ reflections on the care provided in an acute psychiatric ward

There is little research evidence about how the mental health professionals are coping with the complexity of everyday practice in psychiatric acute care. The aim of this study was to explore mental health professionals’ reflections on their work on an acute psychiatric ward. Data were collected using participant observation and interview methods. Three core themes were identified from a qualitative hermeneutic analysis. The first core theme, coping with uncertainty, uncovered a dialectical pattern of the factors contributing to thriving and strain in the working situation. The second core theme, caring for the patient, included the caring process, patients’ pathway to acute psychiatric care, as well as the patients’ needs and roles on the ward. The third core theme, coping strategies, included five different methods the primary nursing system, concealing versus integrating, milieu therapy, seclusion and the medical orientated model. It was concluded that good mental health care is a result of collaboration between health professionals and the health services. This study highlights the need for support to professionals and for establishing structures that will enable collaboration to take place. Taken together, this may contribute to enhancing the care of the patient and their families.     

General practitioners' perceptions of community psychiatric nurses in primary care

The management of and responsibility for the care of people with mental health problems in the community is increasingly being assumed by general practitioners (GPs) and primary care personnel. As primary care groups (PCGs) evolve, so must their expertise in managing people with a wide range of mental health problems. It is expected that all mental health professionals will participate in this development, although it is likely that community psychiatric nurses (CPNs) will be the largest professional group involved, with a significant part to play in the shaping, management and delivery of mental health services. To date, there has been little research into how CPNs are perceived by other primary health care professionals. This study seeks to provide an insight into how GPs assess the contribution of CPNs in primary care. Overall, the results of the study suggest that GPs view CPNs favourably and consider that they have an important role to play. Greater involvement in primary care raises issues about the education and preparation of CPNs, their professional development and supervision needs.     

A conceptual framework for evaluating the conceptualization,implementation and performance of transitional care programmes

Developed health systems want to avoid unnecessary hospital admissions by addressing the needs of chronically ill older adults throughout acute episodes of illness. Transitional care (TC) is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location, of which the main outcome of interest is avoiding hospital readmission. Implementation of TC is complex because it entails different actions to put multiple care components into practice, with various degrees of flexibility of adapting the intervention. Furthermore, the outcome involves behaviour change required by those delivering or receiving the intervention. Although there are examples of promising interventions, the possible variations in conceptualization and implementation present a real challenge for the adaptation of efficacious TC interventions from trial to ‘real‐world’ settings. There is a lack of a theoretical basis or explicit logic model for why adapted interventions should work. This study provides conceptual approaches for the implementation and evaluation of TC programmes. It describes a framework of (1) conceptualization – with respect to the components in an intervention and the population of interest; (2) manner and context of implementation; and (3) evaluation – how these processes of implementation impact health outcomes.     

An evaluation of the implementation of case management in the community psychiatric nursing service

This paper reports the preliminary results of a study on the implementation of case management in the community psychiatric nursing service (CPNS). The purpose of the study is to compare the outcome of case management service with the conventional practice of CPNS in the care of chronic schizophrenic clients. The impact of case management service on clients' clinical status, functional level and satisfaction was measured. A matched, pre-post, case-control group design was used to compare case management and conventional care groups. A specific case management model based on the practice at Carondelet Saint Mary's Hospital and Health Centre in Tucson has been developed to care for the schizophrenic clients in the community. Subjects in the experimental group were cared for by CPNs using this case management model. Subjects in the control group were cared for by CPNs based on current practices in the CPNS. Pre- and post-measures were taken upon recruitment and at 5 months later. Findings showed that the experimental group had better outcome in terms of their mental status and functional level when compared with the control group. They were generally more satisfied with the service. When comparing case managers' role with that of conventional CPNs, case managers performed more in areas such as assessment, liaison, case discussion and life skills training. This study demonstrates that this particular model of case management can be effective in caring for clients with long-term mental health problems in Hong Kong.     

Validation of the Violence Risk Screening‐10 instrument among clients discharged from a psychiatric hospital in Beijing

The Violence Risk Screening‐10 is one of the few instruments available for evaluating violence risk in mental health clients during and after hospitalization. This prospective study examined the applicability of this brief instrument with a sample of 289 clients in the 6 months after discharge from a general psychiatric hospital in Beijing. During the research period, 24 of the 289 clients demonstrated aggression. The receiver–operator characteristic curve yielded an area under the curve of 0.62. At the cut‐off point of 4.5, its sensitivity/specificity was 79.2%/33.3%, and the corresponding positive/negative predictive value was 9.9%/94.5%. The predictive accuracy of this instrument was lower compared with the results of the original study, and was also less accurate than when it was administered while the clients were in the hospital. While promising in its utility for use beyond the hospital, it deserves further modification prior to its wide use across culturally‐diverse China.     

The use of discharge risk assessment tools in general psychiatric services in the UK

Closure of asylums dismantled a system of risk control based on containment, resulting in a rise in homicides and suicides by discharged patients. Remedial action centred on a structured approach to managing multidisciplinary care (the Care Programme Approach) and a system of independent inquiries into homicides. A need for better discharge risk assessment was identified by government and health professions. The literature points to inherent limitations in the predictive power of actuarially based tools, restricting them to augmenting clinical judgement. This paper addresses the development and effective use of tools to predict risk to patients and public following discharge into the community. Methods used were: (i) a questionnaire to NHS Trusts in the UK; (ii) an analysis of documentation on tools in use; and (iii) interviews of hospital and community mental health teams at eight NHS Trusts. Findings point to: (i) a sporadic development of risk assessment tools at Trust level; (ii) that this has been stimulated by clinical governance but is unguided by any coherent national strategy; and (iii) that information technology for risk data collection is not well used in the UK, where there is reliance on use of paper records and informal communication. The implications for management and health professions are discussed.     

Nurses' perceptions of multidisciplinary teamwork in acute psychiatric settings

The findings of a pilot telephone survey of senior nurses' views of multidisciplinary teamwork (MDT) practice in 26 acute psychiatric admission wards within the ambit of one English health authority are reported. The survey was conducted in two stages. The first stage focused on obtaining the senior nurse's general perceptions of the organization of the work of the multidisciplinary team, and in the second stage more detailed responses to the original questions were obtained. The findings suggest that the composition and operations of the acute ward team are limited, and the relationship between the MDT and patients and their families do not entirely support the concept of increased collaboration with patients and their families. The findings are discussed within the context of the perceived crisis in acute psychiatric care in England and the ambitions for more egalitarian 'mental health' services.     

Community psychiatric nurse caseloads and the ‘worried well’: misspent time or vital work?

Community psychiatric nurses (CPNs) in the United Kingdom are being repeatedly urged to focus their attention upon those with serious and enduring psychotic illnesses, and to withdraw from working with the 'worried well' in the primary health care setting. In view of this pressure, it is important to discover the nature of community psychiatric nurses' non-psychotic caseloads. The aim of this study was to describe these cases, what precipitated their referral, what problems they suffered from, what effects these problems had upon their lives and what kinds of therapeutic interventions they were receiving. A random sample was drawn of non-psychotic CPN patients. The community psychiatric nurses then received a structured interview about the history, care and treatment of these patients. These patients did not, in general, suffer from minor, self-limiting conditions. They typically had had 5 years of contact with psychiatric services, and their psychiatric symptoms blighted their occupational, social and personal lives. Their condition caused significant carer burden, and there was frequently a risk of suicide. The CPNs case-managed a complex combination of interventions for these patients, of which psychotherapeutic methods were only one part. The findings show that community psychiatric nurses have a valid role to play in the care of those with non-psychotic mental disorders, and should continue to receive the opportunity, and appropriate training, to do so.     

The relationship between community psychiatric nurses and clients with severe and persistent mental illness: The client’s experience

The aim of this phenomenological study was to construct an interpretation of the experience of nurse–patient relationships, in the context of community psychiatric nursing. The purpose of this paper is to focus on the experience of the relationship from the perspective of the clients. Themes of ‘having someone looking out for me’, ‘working in collaboration’, and ‘being understood and gaining understanding’ were identified. This thematic structure was used to understand the meaning of the relationship for the clients. Implications for practice, education, clinical supervision and mental health services are discussed.