Mental health training for nursing home staff using computer-based interactive video: a 6-month randomized trial

OBJECTIVE: Mental health education for the staffs of nursing homes is difficult to provide and often inadequate. The objectives of this study were to design and assess a curriculum of staff training on depression and dementia that is accessible, educational, and relevant. DESIGN: A core curriculum of 12 computer-based interactive video training modules was created in a television news-documentary format to educate nursing home staffs. A randomized trial of the first six modules, which are dedicated to mental health and aging, was conducted at a computer site (CS), a "lecture site" (LS), and control site (CON). SETTING: Three not-for-profit nursing facilities in Western Pennsylvania. PARTICIPANTS: The certified nursing assistants, and other nursing staff participated in the study as part of their required training. INTERVENTION: Nursing staffs at the two intervention sites (CS and LS) were mandated to participate in monthly educational sessions. At the CS, the computer program scheduled staff members each month for 45 minutes of individual, self-paced training using the interactive video modules. At the LS, staff members were scheduled to attend a 45-minute monthly lecture with identical learning objectives delivered by an advanced degree nurse educator. A videotape of the lectures was shown at two additionally scheduled times during the month to accommodate all shifts. MEASUREMENTS: Compliance and satisfaction with training were monitored at both intervention sites. Knowledge was assessed at the CS, LS, and CON, before each monthly training session, and with a cumulative post-training exam, administered at the end of the 6-month study. RESULTS: Over the 6-month period, training compliance was 66% and 22% at CS and LS, respectively (P < 0.001). Satisfaction with training and the relevance of training were rated significantly higher at the CS (P < 0.0001). Before the study, assessed knowledge was similar at the CS, LS, and CON. After 6 months, the CS scored significantly higher than the LS and CON in terms of knowledge (P < 0.005). CONCLUSION: Individual, self-paced, interactive video education for nursing home staff resulted in greater compliance and satisfaction with training compared to staff receiving lectures. Knowledge of core concepts was greater for staff of the computer site compared to the staffs of either the lecture or control sites at the end of this 6-month study.     

Developing community mental health services: an evaluation of Glasgow's mental health resource centres

Greater Glasgow Health Board's strategy for the development of community mental health services includes the establishment, over a 7-year period, of multi-disciplinary community mental health resource centres throughout Glasgow. An evaluation of the first phase of the development was carried out in three resource centres. This focused on three key themes: the establishment of multi-disciplinary teams, targeting of those with the most severe illnesses and the participation of users in the care process. The evaluation exercise comprised five substantive elements: analysis of the clinical database; interviews with staff within each of those centres, interviews with representatives of key external agencies associated with each centre; a survey of general practitioners; and a survey of the views of clients, their carers, their key workers, and their general practitioners (GPs). Clients were generally very satisfied with the services and felt that the resource centres met all their mental health needs. Although the majority of current centre cases had severe mental illnesses and those with the more severe conditions had the highest contact rates there was evidence that in the absence of a clear framework for referral the centres were also providing services for those with less severe illnesses. Despite a wish by centre staff to move towards modes of working less dominated by health professionals and more inclusive of other resources and especially of clients themselves, these goals remained to be achieved: there was a lack of clarity in the definition of the appropriate target groups for the centres; access to crisis support was regarded as problematic; the concept of multi-disciplinary team working had yet to be fully realized with evidence suggesting that some psychiatrists working in the resource centres had not embraced many aspects of the new approach to service delivery including a focus on the severely ill; and progress towards the ideal of active client involvement had been slow.     

Reluctant empiricists: community mental health nurses and the art of evidence-based praxis

The National Service Framework for Mental Health (1999) emphasizes the need for a culture of evidence-based practice (EBP) in mental health care. However, there is relatively little research addressing EBP from the perspective of community mental health nurses and we are still unsure of why the uptake of this style of working has been slow. This paper suggests that rather than thinking in terms of 'barriers' to the uptake of EBP, the issue may best be conceptualized as a form of praxis on the part of nurses, as they seek to manage the diversity of ideologies and practices in their working lives. From an interview and focus group study, we identify how practitioners' narrow definition of EBP itself, their formulation of how EBP was at odds with the nurse's professional activity and the organizational constraints within which they work were perceived to inhibit access to information and offer little time and managerial support for information seeking. Those who attempt to further the involvement of community mental health staff in EBP will have to reconceptualize the reasons why staff have yet to incorporate it fully, and acknowledge that this does not occur because staff are simply 'ignorant Luddites', but that this resistance enables them to retain a sense of control over their working lives and retain a focus on work with clients. Future EBP initiatives will have to address these ideological and organizational factors in order for uptake to be accelerated. This may involve changing organizational cultures and work roles and even encouraging activism on the part of the practitioners so as to enable them to learn from each other and educate and change their work environments.     

Balancing hospital and community treatment: effectiveness of an extended-hours community mental health team in a semi-rural region of australia

Objective: To examine the effectiveness of the introduction of a community mental health team on consumer psychosocial outcomes. Design: Longitudinal panel design. Setting: District general hospital in a semi‐rural region of Australia. Numbers: Two matched groups (n = 37 in each group) Main outcome measure: These included: Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), Rosenberg Self‐Esteem, Life Skills Profile as well as self‐report. Results: The study found that the introduction of the new service resulted in few significant differences in consumer outcomes. Conclusions: The paper argues that because the state was the only specialist mental health service provider and it was unable to offer assertive community treatment, hospital care remained central. Evidence that a substantial proportion of consumers and carers preferred hospital to community care is placed against this background. The paper argues that in regions like these, where community‐based services are likely to remain underdeveloped, it may be best to maintain quality hospital services and to target community services more precisely on what is achievable rather than developing community services at the expense of hospital care. What is already known: Studies on the efficacy of assertive community treatment suggest that it can lead to improved consumer outcomes. However, these studies are usually in urban settings and involve experimental teams. In many rural and regional areas community treatment teams offer standard rather than assertive community care. It is therefore important to investigate the effectiveness of community treatment teams in rural and regional Australia. What this study adds: This study suggests that in rural and regional areas characterised by limited resources, it is too much to expect community treatment teams to have a measurable impact on consumer outcomes. In these settings hospital care remains at the heart of the service. This means that regions such as these need to focus their community services on what is achievable given the level of resources and social ecology. For example, they may need to consider offering either crisis intervention or rehabilitation services and to rely on innovations, such as telehealth or strategic alliances with other service providers to fill the gap.     

Pattern of general practitioners' referrals to a rural community mental health centre: a 3-year analysis

Community mental health centres (CMHCs) represent a major trend towards developing locally based community psychiatric services. The Beaconfield Centre described here is an example of a rural project which aims to provide comprehensive and accessible psychiatric services to the population of the town of Grantham, in south Lincolnshire. The rate and pattern of referrals to the Beaconfield Centre over a period of 3 years are examined. It was found that the bulk of the general practitioners' (GPs) referrals were directed mainly to Community Psychiatric Nurses (CPNs), 49%, followed by the Consultant Psychiatrists, 42%. GPs considered the nature of the patient's problem to be responsible for nearly 20% of the total referrals. More work is required to test the appropriateness of these referrals and assess the degree of congruence between the GPs' and the mental health team's perception. The paper also highlights the need to assess regional variations in the function of these centres and their relationship to both primary health care and traditional psychiatric services. The future composition and the policy of referrals to the Community Mental Health Team (CMHT) need to be reviewed, particularly in relation to the growing number of fund holding general practices. The future role of all mental health professionals working in community settings urgently needs to be redefined with reference to the role of the CPNs vis á vis day care nurses.     

社区心理卫生服务人员心理疾病识别能力分析

目的 了解社区心理卫生服务人员对常见心理疾病的识别能力。方法 采用随机整群抽样方法,抽取北京市朝阳区、哈尔滨市南岗区和克拉玛依市克拉玛依区的165名心理卫生服务人员进行问卷调查。结果 北京市朝阳区心理卫生服务人员对抑郁症的正确识别率为79.6%（39/49）,高于克拉玛依市的43.6%（24/55）和哈尔滨市的60.7%（37/61）,差异均有统计学意义（P<0.05）;对焦虑症的正确识别率为77.6%（38/49）,高于克拉玛依市的25.5%（14/55）和哈尔滨市的16.4%（10/61）,差异均有统计学意义（P<0.001）;对精神分裂症的正确识别率为93.9%（46/49）,高于哈尔滨市的50.8%（31/61）和克拉玛依市的43.6%（24/55）,差异均有统计学意义（P<0.001）;对躁狂症的正确识别率为77.6%（38/49）,高于哈尔滨市的45.9%（28/61）和克拉玛依市的47.3%（26/55）,差异均有统计学意义（P<0.001）;对强迫症的正确识别率北京市为98.0%（48/49）,哈尔滨市为47.5%（29/61）,克拉玛依市为65.5%（36/55）,差异均有统计学意义（P<0.05）。结论 3个地区社区心理卫生服务人员对心理疾病的识别能力有待提高,应进一步提高服务人员的理论知识和业务水平。     

Tackling community integration in mental health home visit integration in Finland

Integration – and its synonym inclusion – is emphasised in the western welfare states and in the European Union in particular. Integration is also a central topic in the social sciences and in current mental health and homelessness research and practice. As mental healthcare has shifted from psychiatric hospitals to the community, it has inevitably become involved with housing and integration issues. This article explores how community integration is understood and tackled in mental health floating support services (FSSs) and, more precisely, in service user–practitioner home visit interaction. The aim, through shedding light on how the idea of integration is present and discussed in front‐line mental health practices, is to offer a ‘template’ on how we might, in a systematic and reflective way, develop community integration research and practice. The analysis is based on ethnomethodological and micro‐sociological interaction research. The research settings are two FSSs located in a large Finnish city. The data contain 24 audio‐recorded and transcribed home visits conducted in 2011 and 2012 with 16 different service users. The study shows how the participants in service user–practitioner interaction give meaning to community integration and make decisions about how it should (or should not) be enhanced in each individual case. This activity is called community integration work in action. Community integration work in action is based on various dimensions of integration: getting out of the house, participating in group activities and getting along with those involved in one's life and working life. Additionally, the analysis demonstrates how community integration work is accomplished by discursive devices (resistance, positioning, excuses and justifications, delicacy and advice‐giving). The article concludes that community integration is about interaction: it is not only service users' individual challenge but also a social challenge, our challenge.     

Case management in mental health services:the role of community mental health support teams

The progressive reduction in the numbers of hospital places available for people with mental health problems has led to an increasing demand on community support services. One response has been the development within social services departments of community mental health support teams, which employ largely unqualified staff who offer support to people with longer term mental health needs. The paper examines to what extent the practice of one authority's support teams reflects an appropriate ‘case management’ style of service, as developed in the USA to address the needs of long-term community patients. Key features of this approach are identified, and used as the basis of analysis of the support teams' practice in relation to 214 cases. It is concluded that a ‘case management’ model can be appropriate for work involving unqualified staff, provided that the service structure as a whole enables access to other skills as appropriate. Two specific risks are identified: firstly that the service is developed because of cost rather than appropriateness; and secondly that the service can rapidly become silted up with increasing numbers of people who need service of indefinite duration.     

Joint working in community mental health: prospects and challenges

This paper reviews the opportunities for, and the challenges facing, joint working in the provision of community mental health care. At a strategic level the organization of contemporary mental health services is marked by fragmentation, competing priorities, arbitrary divisions of responsibility, inconsistent policy, unpooled resources and unshared boundaries. At the level of localities and teams, these barriers to effective and efficient joint working reverberate within multi-disciplinary and multi-agency community mental health teams (CMHTs). To meet this challenge, CMHT operational policies need to include multiagency agreement on: professional roles and responsibilities; target client groups; eligibility criteria for access to services; client pathways to and from care; unified systems of case management; documentation and use of information technology; and management and accountability arrangements. At the level of practitioners, community mental health care is provided by professional groups who may have limited mutual understanding of differing values, education, roles and responsibilities. The prospect of overcoming these barriers in multidisciplinary CMHTs is afforded by increased opportunities for interprofessional 'seepage' and a sharing of complementary perspectives, and for joint education and training. This review suggests that policy-driven solutions to the challenges facing integrated community mental health care may be needed and concludes with an overview of the prospects for change contained in the previous UK government's Green Paper, 'Developing Partnerships in Mental Health'.     

Researching the implementation of community mental health promotion programs

Understanding the process of program implementation plays a critical role in advancing research, practice and policy in mental health promotion. This paper focuses on the implementation of community mental health promotion and considers the challenges presented in implementing and evaluating complex, multifaceted interventions carried out in the context of dynamic community settings. The Rural Mental Health Project1–3 is presented as a case study to illustrate the practical and research challenges encountered in implementing and evaluating a community mental health promotion initiative. This case study highlights the factors that contributed to the successful implementation and evaluation of a community‐based intervention for rural communities on the border region in the Republic and Northern Ireland. Among the factors identified are: a partnership model of working; local co‐ordinating structures and consultation mechanisms; use of a structured planning model to guide program planning and implementation; mobilisation of cross‐community and inter‐agency support; and a comprehensive logic evaluation framework to assess the input, process, impact and outcomes of the project as it unfolded.     

The impact of community mental health reform on service users: a cohort study

British mental health services have undergone considerable reform in recent years. This paper reports a study designed to assess the impact of these changes on service users. The functioning of 100 randomly selected users of community mental health services in a North Wales town was assessed before the advent of two significant service changes – the establishment of a local Community Mental Health Team (CMHT) and the introduction of the main community care reforms in April 1993. Repeat assessments of sample members were made on three further occasions over the following 27 months, with a 9-month interval between each. Comparison of baseline and follow-up data suggested that services were appropriately targeted on users with a severe and enduring mental illness and that the functioning of this client group was successfully maintained over the study period. However, the establishment of a CMHT was associated with a temporary fall in social functioning, quality of life and satisfaction with services and there was no evidence to conclude that organizational reforms had led to an improvement in user outcomes in the medium term. Future mental health reorganization should be based on the evidence of research which includes an assessment of the impact of reforms on service users.     

The development of a community child and family mental health service

The Community Child and Family Service is a primary care and community-based child mental health service working in a socio-economically disadvantaged area of inner London. This paper outlines the strategic framework and value base from which the service has developed. The clinical projects set up by the service in general practice, community and education settings are described, as are the training and supervision programmes that have been undertaken. The framework for evaluating the clinical and economic outcomes of the projects is outlined. There has been a positive response from purchasers, providers and clients to the introduction of this Service. The relationship between community- and hospital-based child mental health services is discussed, as is the future direction of the Service.     

A comparative analysis of six audit systems for mental health nursing.

PURPOSE: To devise an analytical framework to help identify strengths and weaknesses in the audit process as specified by existing psychiatric nursing audit systems, in order to analyse current audit practice and identify improvements for incorporation in the Newcastle Clinical Audit Toolkit for Mental Health. DATA SOURCES: Published material relating to the following six systems: the Central Nottinghamshire Psychiatric Nursing Audit; Psychiatric Nursing Monitor; Standards of Care and Practice; Achievable Standards of Care; Quartz; and Quest. DATA EXTRACTION: Comparison of the six systems according to an analytical framework derived from detailed empirical study (structures, processes and outcomes) of one of them in use and the educational evaluation literature. Examination of the extent to which guidance is provided for operating the systems and for wider process-related aspects of audit. RESULTS OF DATA SYNTHESIS: Five of the systems failed to specify some important elements of the audit process. Conceptually, the six systems can be divided into two main types: 'instrument-like' systems designed along psychometric lines and which emphasize the distance between the subjects of audit and the operators of the systems, and 'tool-like' systems which exploit opportunities for care setting staff to engage in the audit process. A third type of system is the locally-developed system which is offered to a wider audience but which does not make the same level of claim to universal applicability. CONCLUSION: The analytical framework allows different approaches to audit to be compared and contrasted not only according to the techniques used, but also according to process issues. The analysis of six systems revealed a variety of different techniques and procedures which can facilitate, in a methodologically rigorous manner, practitioner and other stakeholder involvement in audit processes.     

The social utility of community treatment orders: Applying Girard’s mimetic theory to community‐based mandated mental health care

Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non‐compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.     

The challenge of managing community mental health teams

Although community mental health teams (CMHTs) have become the main vehicle for coordinating health and social care for people with severe and long-term mental health problems, little research exists on their management. This paper reviews the available literature with reference to the wider literature on innovation and organizational behaviour and examines strategies for improving CMHT management at macro and team level. The challenges of researching the topic are described with recommendations for further research based on social constuctivist theorizing and triangulated methodology.     

Fear and Shame: using theatre to destigmatise mental illness in an Australian Macedonian community

In the article entitled ‘Fear and Shame: using theatre to destigmatise mental illness in an Australian Macedonian community’ by Blignault et al., an incorrect year was used. Page 124, col. 2, para 3, line 3 should read: When asked who they would contact for help if someone they knew was showing signs of mental illness, 84% of the overall sample nominated health workers or services in 2009 compared to 60% in 2003 (see Table 5).