The truth is in the eye of the beholder? Quality in rehabilitation from the patients' perspective

The definition of "good" quality in health research and quality management in health care and rehabilitation are primarily based on health professionals and their associations. But laypersons, patients, and participants in rehabilitation programmes, too, develop cognitive concepts about what defines good quality in health care. Until now systematic knowledge about the role of the patients' views on quality in rehabilitation is rare. Existing data demonstrate that patients report detailed ideas about indicators and preconditions of good quality of rehabilitative care. Patients' quality concepts differ in some aspect from the quality definitions of health care professionals. There is some evidence that patients' views on quality are a necessary extension and completion of programme evaluation and of quality management. They influence usage and selection of rehabilitation facilities and programme elements and probably patient satisfaction and long-term outcomes as well. Patients' ideas could contribute to gaining a deeper understanding of patients' needs. Here, patients are experts to define challenges for long-term improvements in health and health-related behavior with regard to everyday life and related resources and barriers. Taking patients' views on the quality of rehabilitation into account could help to adapt rehabilitation features, programmes and long-term offers more adequately to patients' needs. More systematic evidence is however needed as a basis for further developments in rehabilitation programmes.     

The evolution of a token economy programme for female chronic schizophrenic patients

Token economy programmes are becoming an increasingly familiar sight in British psychiatric hospitals, yet many remain inflexible and prone to breakdown after a period in operation. This paper describes the evolution of a token economy for female chronic schizophrenic patients, where the nursing staff with minimal 'psychological' support and in dealing with a programme free of research constraints, aimed to increase the therapeutic potential of the system. The major developments arose from the need: (i) to extinguish the emergence of undesirable behaviour; (2) to develop a more individualized approach to treating patients' problems; (3) to keep consistent adequate records; (4) to re-establish contact with the community and (5) to cater for patients' varied responses to treatment.     

代币制疗法在慢性精神分裂症患者康复训练中的应用

目的:探讨代币制疗法在慢性精神分裂症患者康复训练中的应用方法及临床效果。方法:对30例慢性精神分裂症住院患者应用代币制疗法进行康复功能训练,并使用住院患者观察量表(NOSIE)和症状自评量表(SCL-90)进行治疗效果评价。结果:实施代币制疗法6个月,患者NOSIE评分及SCL-90评分与治疗前比较差异有统计学意义(P<0.01)。结论:将代币制疗法应用于慢性精神分裂症住院患者的康复训练,可明显改善其精神症状和生活能力,值得临床推广应用。     

Occupational rehabilitation of psychiatric patients in an occupation-specific facility--results of a study

The day structure of persons with acute or chronic mental illness is a central problem field in the design of helping and supportive programmes. The specifics involved in chronic mental illness must therefore be taken into account to a sufficient degree. A specialized vocational rehabilitation centre has been established in Vienna in the process of reorganization of psychiatric care. The study presented, which comprised the 441 persons who had participated in programmes at the Centre during the initial six years of its operation, shows that rehabilitative intervention in particular has positive effects when taking place before premature pensioning. A follow-up study of 294 former programme participants found that a total of 132 persons (i.e., 44.9%) had been working permanently or at least occasionally after programme completion. Given the fact that the majority of rehabilitation interventions provided had occurred in cases deemed prognostically unfavourable, the findings clearly show the importance of specialized facilities. No significant influence on the course of rehabilitation was found to be related to age, sex, psychiatric diagnosis and frequency/duration of previous hospitalizations. The rehabilitative process took a more favourable course in persons whose stay in the Centre had extended beyond six months.     

Behaviour modification in nursing practice and research: a case study

Using a behaviour modification programme, an attempt was made to teach a 39-year-old dependent patient with a medical diagnosis of schizophrenia to reacquire and maintain self-care behaviours. Dependence in this project was limited to morning care behaviours, i.e. mouth-washing, face-washing, shaving and bathing. Praise and a token economy programme were used to reduce the number of prompts (help and reminders) the patient needed to accomplish the targeted behaviours. Although the treatment programme ran for only 4 weeks because the patient was prematurely transferred to another ward, an evaluation of the programme shows that nursing staff in psychiatric hospitals can facilitate healthy behaviours in schizophrenic patients through behaviour management skills.     

Questionnaire test-retest reliability: outcome measure of a vocational rehabilitation programme

In a clinical follow-up case series study, the test-retest reliability of an outcome measure questionnaire was tested. The study group consisted of 48 patients who had taken part in a vocational rehabilitation programme. Test-retest reliability of a questionnaire was evaluated with the reliability index two years after entering the programme. It was found that the test-retest reliability of demographic data was rather good, although the questions concerning basic and occupational training showed instability over time. The answers concerning general health symptoms, mental working capacity and perceived changes in life during the past 12 months showed particularly high variability. The respondents' opinions on their general outlook of life seemed rather stable. Opinions about the perceived benefits from the intervention were marginally stable. The respondents' opinions about the benefits perceived from the physicians' work were more stable than the opinions about the perceived help from the other members of the rehabilitative team. It was concluded that an outcome analysis questionnaire is a useful tool to document the respondents' general and present perception of life and their present health situation as well as the rehabilitation process. The further development of generally applicable outcome measures for health promotion programmes will require unified, long-term efforts.     

精神科开放式病区护理和管理

目的探讨对精神病患者进行开放式病区护理和管理的治疗和康复的影响。方法对精神科实行开放式病区护理和管理及开展各种训练。结果开放式病区护理和管理提高了治疗和康复的效果。结论多年来，对于精神病患者实行开放式病区管理，是提高治疗和康复的有效方式，同时也提高了患者对医院的服务和技术的满意。     

Work-therapy in psychiatric rehabilitation

The programme in a rehabilitation unit is described, with special emphasis on the role of work for chronic patients. Features include the "ladder-principle" approach to the patients' activity, the reorganization of payments and the use of hostels in the community as a way to discharge for patients achieving the higher levels both in salaries and resocialization. Two basic rules with predictive value are tentatively established: 1) middle-aged patients have the best rehabilitative prospects, 2) results of the rehabilitation process are in inverse proportion to the length of previous unemployment.     

Predicting non-return to work in patients attending cardiac rehabilitation

Return to work (RTW) is the primary goal in the rehabilitation of patients suffering from coronary heart diseases. However, in spite of expensive rehabilitative efforts, many patients do not resume work following cardiac rehabilitation. To increase cost-effectiveness, predictive tests for non-RTW are needed to identify patients who are at risk of applying for early retirement, for reasons other than medical ones, at the beginning of the rehabilitation process, so that the necessary intervention is incorporated into the rehabilitation programme. As part of a study aiming at developing an advisory programme which can be integrated into existing rehabilitation programmes, we developed a screening instrument for the identification of persons at risk of not returning to work at the onset of the rehabilitation process. More than 65% of the participants who had not returned to work 6 and 12 months following rehabilitation had been correctly identified as risk patients at the beginning of the rehabilitation process. Seventy-five percent had been correctly identified as not being at risk. Multiple regression analysis results showed that increased age, profession, positive expectations concerning RTW and level of depression were significant predictors of RTW. Gender and anxiety were not significant predictors.     

Expressed emotion on long-stay wards

We examined the influence of an educational programme on nurses' level of expressed emotion (EE), on ward climate and on social functioning and psychopathology of hospitalized schizophrenic patients Nurses and patients were from long-stay wards of six Dutch psychiatric hospitals Despite an increase of nurses' knowledge about schizophrenia we did not find measurable effects on nurses' levels of EE According to the five minute speech sample method, a third of the nurses participating in this study had a high level of expressed emotion, mainly consisting of criticism This was a rather stable pattern Patients, however, were reluctant to give their nurses high EE ratings on the level of expressed emotion scale Psychopathology was not influenced by the educational programme, but social functioning of patients was related to EE in nurses Moreover, we found a significant decline in the number of restrictive ward rules at follow-up We conclude that, while it may be difficult to detect changes in EE level after an educational programme for nurses, there nevertheless appear to be measurable benefits for patients     

The ward atmosphere of single-sex wards in a maximum-security forensic psychiatric hospital in Sweden

This exploratory study investigated the ward atmosphere of single-sex wards in a forensic psychiatric context in the light of Moos' conceptualization of the treatment setting. The wards for female patients bore similarities to Relationship-Oriented and Insight-Oriented programmes and had a generally positive ward atmosphere. On the other hand the wards for male patients did not resemble any treatment programme and had a more mixed diagnosis profile than those for female patients. Comparisons of the two types of wards are made and implications of the findings in terms of the overriding principle of normalization are discussed.     

The Ward Atmosphere of Single-Sex Wards in a Maximum-Security Forensic Psychiatric Hospital in Sweden

This exploratory study investigated the ward atmosphere of single-sex wards in a forensic psychiatric context in the light of Moos' conceptualization of the treatment setting. The wards for female patients bore similarities to Relationship-Oriented and Insight-Oriented programmes and had a generally positive ward atmosphere. On the other hand the wards for male patients did not resemble any treatment programme and had a more mixed diagnosis profile than those for female patients. Comparisons of the two types of wards are made and implications of the findings in terms of the overriding principle of normalization are discussed.     

Planning and evaluating innovations in nursing practice by measuring the ward atmosphere

A controlled evaluation of nurses' and patients' perceptions of the hospital ward atmosphere served to both define problems and evaluate the corrective changes that were implemented in a psychiatric day hospital. The results indicated that nurses and patients held similarly unfavourable views of the ward at a baseline assessment, including low levels of support, involvement, spontaneity and programme clarity. This finding then served as the basis for systematic changes, including staff training, the regrouping of patients, and revising the therapeutic programme. A repeat evaluation then indicated that these changes had significantly improved the ward atmosphere from the perspective of both nurses and patients. It is concluded that this approach holds considerable promise for the implementation of changes in nursing practice.     

早期与晚期康复治疗对脑梗死病人功能恢复影响的对照研究

目的探讨早期与晚期康复治疗对脑梗死病人功能恢复的影响。方法选择216例脑梗死病人,其中早期康复组与晚期康复组各108例。早期康复组在病人生命体征稳定、神经病学体征不再进展2周内开始康复治疗。晚期康复组在发病2周后开始康复治疗。两组均采用Bobath法和运动再学习法进行训练。采用改良巴式指数(MBI)、简式Fugl-Meyer运动评分(FMA)和临床神经功能缺损程度评分进行康复评价。结果临床神经功能缺损程度评分、FMA和MBI入组时两组均无统计学差异(P>0.05),治疗30d后两组均较治疗前明显改善(P<0.001),早期康复组较晚期康复组改善程度更大(P<0.05)。结论早期与晚期康复治疗均可明显促使神经功能恢复,但早期康复组临床疗效明显优于晚期康复组。     

A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China

Aim. The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu, China. Background. Epidemiological studies indicate a dose‐, level‐ and duration‐dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality. Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes. Design methods. A randomized controlled trial was conducted. Coronary heart disease patients (n = 167) who met the sampling criteria in two tertiary medical centres in Chengdu, south‐west China, were randomly assigned to either an intervention group (the cardiac rehabilitation programme) or control group (the routine care). The change of health behaviours (walking performance, step II diet adherence, medication adherence, smoking cessation) and physiological risk parameters (serum lipids, blood pressure, body weight) were assessed to evaluate the programme effect. Results. Patients in the intervention group demonstrated a significantly better performance in walking, step II diet adherence, medication adherence; a significantly greater reduction in serum lipids including triglyceride, total cholesterol, low‐density lipoprotein; and significantly better control of systolic and diastolic blood pressure at three months. The majority of these positive impacts were maintained at six months. The effect of the programme on smoking cessation, body weight, serum high‐density lipoprotein, was not confirmed. Conclusions. A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients. Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease. Relevance to clinical practice. This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients. Furthermore, the hospital–home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care.     

康复病房实施人性化护理的效果

目的探讨人性化护理在康复病房中的应用效果。方法将康复病房440例住院患者随机分为观察组(228例,采用人性化护理)和对照组(212例,采用传统护理方法)。每组抽取40例,接受住院患者满意度调查。结果对照组患者对护士的服务态度、技术操作、健康知识宣教的满意度分别为72.5%、75%和67.5%,观察组均为100%,两组间的差异有非常显著性意义(P<0.01)。结论在康复病房开展人性化护理可提高医疗护理服务质量和住院患者的满意度。     

Rehabilitation of pension--which course do psychiatric patients follow after their first inpatient treatment in a psychiatric hospital? Results of a prospective longitudinal study

Placing persons having a mental illness in the open labour market has in recent years become increasingly difficult. The question therefore arises whether an attempt should be made to improve occupational access through rehabilitative measures, or whether pensioning would not be the more appropriate action. In the framework of a prospective 5-year catamnestic study of first-admission psychiatric patients, the course taken by them was investigated, as well as the factors that had been relevant in the decision to pension the patients, or to provide rehabilitative services. It was found that pensioning and rehabilitative measures differ in no essential degree as to their shares, and that both types of approach had occurred in only very few cases. Disease-specific factors (psychopathological symptoms, readmission) are suggested to be involved concerning the route taken. Pensioning on the one hand, and rehabilitation service provision on the other, are linked with the age and diagnoses of the patients, as well as the extent of their social activities.     

Clinical teaching of group dynamics: an evaluation of a trial clinical teaching programme

This paper describes the implementation and evaluation of a trial teaching programme designed to prepare nursing students to function in a group therapy setting. While the theory and principles of group therapy are not discussed in detail, these educational aspects form a crucial part of students' preparation for the practical experience of group work. The teaching programme was designed and carried out by one of the writers (W.R.), who functioned in a dual role as both classroom tutor and clinical teacher. This dual role function is seen as central to the success of the trial in that is facilitated a strong link between theory and practice. Additionally, this approach sought to reduce the distance which is often perceived by clinicians as existing between the ‘reality’ of nursing practice in clinical situations, and the theory which students are taught in classrooms.A teaching programme was provided for four post-registration (registered mental nurse) students in a long-stay psychiatric ward. The outcome of the programme was evaluated by the patients and students who participated in the therapy, and by their teachers. It is proposed that the classroom/clinical links described in this paper facilitated the successful teaching of group psychotherapeutic skills. It is also proposed that the therapeutic skills and the teaching method described are of relevance to all nurses.     

A National Health Service Hospital's cardiac rehabilitation programme: a qualitative analysis of provision

Aim. This paper reports a study examining the effectiveness of a London National Health Service Trust Hospital's cardiac rehabilitation programme, from the perspectives of healthcare professionals and patients. Background. Cardiovascular disease is the world's leading cause of death and disability. Substantial research has reported that, following a cardiac event, cardiac rehabilitation can promote recovery, improve exercise capacity and patient health, reduce various coronary artery disease risk factors and subsequently reduce hospitalization costs. Despite these findings and the introduction of the National Service Framework for Coronary Heart Disease, there is wide variation in the practice, management and organization of cardiac rehabilitation services. Methods. A purposeful sample of three postmyocardial infarction patients registered on the selected hospital's cardiac rehabilitation programme, coupled with 11 healthcare professionals were selected. The patients acted as individual case studies. The authors followed all three patients through phase III of their cardiac rehabilitation programme. The research attempted to explore the roles and procedures of a London hospital's cardiac rehabilitation programme through an interpretative framework involving qualitative research methods. Participant observation and in‐depth semi‐structured interviews were the instruments used to collect data. Findings. Whilst the healthcare professionals were enthusiastic about coronary heart disease prevention, the London NHS trust hospital's cardiac rehabilitation programme had several barriers, which reduced the programme's success and prevented it from achieving National Service Framework targets. The barriers were complex and mainly included service‐related factors, such as lack of professional training, weak communication between primary and secondary care and confused roles and identities. Conclusion. Although the study has immediate relevance for the local area, it highlighted issues of more general relevance to cardiac rehabilitation and secondary prevention programme development, such as communication and role and identity perceptions in a multi‐professional working environment and the need to develop a formal training programme for cardiac rehabilitation healthcare professionals. Relevance to clinical practice. The results of this study highlight the need for increased investment, improved planning and the introduction of a comprehensive training programme for healthcare practitioners in cardiac rehabilitation. Implementation of these actions may reduce many of the service limitations and barriers that currently surround cardiac rehabilitation programmes.