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.     

Linking individual and organizational wellness

In addition to intervening when workers have substance abuse or stress problems, many hospital employee assistance programs (EAPs) now include a wellness component that emphasizes prevention and organizational wholeness. The EAP at St. Joseph's Hospital & Medical Center, Paterson, NJ, has taken a number of steps to improve its responsiveness to employees' needs and promote constructive organizational changes. To meet increasing requests for mental health services, St. Joseph's EAP implemented a short-term (up to 12 sessions) counseling program that focuses on problem-solving techniques. The EAP has also used feedback from clients to address organizational issues. For example, a survey that revealed differences between managers' and employees' perceptions of managers' leadership skills has led St. Joseph's to consider development of further workshops to train managers on how to be more effective leaders. And in response to complaints from nurses about a lack of communication with physicians, St. Joseph's invested $8,000 to implement nursing support groups and seminars to enhance nurse-physician collaboration. Additional EAP activities include consulting services for other corporations and help for employees in overcoming financial barriers to access to healthcare and social services. As budgets tighten, effective marketing of EAPs will be essential to their continued growth. In particular, EAP administrators must learn how to document the strategic and financial benefits of their programs.     

Development of evidence-based practice in occupational health services in Sweden: a 3-year follow-up of attitudes,barriers and facilitators

Purpose

The Swedish government initiated an investigation of how to secure and develop the competence of the occupational health services. The primary aim of the present study was to investigate whether the development of evidence-based practice (EBP) in the Swedish occupational health services in relation to attitudes, knowledge and use improved during the first 3 years of the government’s initiative.

Methods

The study has a mixed methods design combining questionnaires and interviews with data collection at baseline and at 3-year follow-up.

Results

The response rate was 66% at baseline and 63% at follow-up. The results show that practitioners’ knowledge of EBP was moderate at baseline and improved at follow-up (p?=?0.002; 95% CI 0.01; 0.21). Practitioners experienced lower levels of organizational and managerial support for EBP at follow-up (p?<?0.001; 95% CI 0.18; 0.38). The results revealed that managers viewed responsibility for implementing EBP as a matter for individual practitioners rather than as an organizational issue.

Conclusions

Occupational health service managers and practitioners are generally positive to EBP. However, the findings emphasize the need to educate managers in how to support EBP at the organizational level by creating an infrastructure for EBP in the OHS.

     

The therapeutic value of fees: What do practitioners believe?

Theorists have proposed that out-of-ocket fee payment helps clients benefit from psychotherapy. 159 staff members of a public mental health agency completed a fee attitude survey. Aggregate results indicated neutral beliefs. Significant differences appeared by gender, population served, and organizational role. Women were less likely than men to endorse TVF beliefs. Addiction services staff held strongest TVF beliefs, child and adult mental health staffs were neutral, and victim services staff rejected TVF beliefs. Clinical service providers were less likely to endorse TVF concepts than were clinicians in management roles, and non-clinical support staff held the strongest TVF beliefs. By understanding the relationships between fee attitudes, organizational role, and populations served, mental health administrators may be better able to manage changes in fee procedures.     

Organizing mental health services: an evidence-based approach

BACKGROUND AND AIMS: Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. FRAMEWORK: Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of "asylum treatment" and "community care". Hospitals and community mental health centers are viewed as treatments with indications and "dosages", such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. METHODS: Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. RESULTS: Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. "partial hospitalization"), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. "integrated treatment" for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities - each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. IMPLICATIONS: A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance.     

Collaboration among state and local mental health organizations: Examples of knowledge utilization

The 1989 Spring issue of the JMHA focuses on knowledge utilization strategies leading to successfulcollaborations among state and local mental health organizations. Prepared by state (or large county) directors/commissioners, five articles in this issue reveal how organizational design, incentives, performance contracting, organizational control strategies, decentralization, and consensus building contribute toimprovements in local mental health services.     

Improving Patient Safety in Hospitals: Contributions of High-Reliability Theory and Normal Accident Theory

Objective. To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices.
Data Sources/Study Setting. We reviewed and drew examples from studies of organization theory and health services research.
Study Design. After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA).
Principal Findings. HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors.
Conclusions. Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures.     

Toward the Implementation of Mental Health Consumer Provider Services

Encouraged by the New Freedom Commission, mental health systems such as the Veteran Administration (VA) are now becoming more recovery-oriented. Consumer providers (CPs)—those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems—are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed, and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.Alexander S. Young, MD, MSHS, Director, Health Services Unit, VISN 22 MIRECC, West LA VA Healthcare Center, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA.Joseph Hassell, MA, Program Coordinator, Health Services Unit, VISN 22 MIRECC, West LA VA Healthcare Center, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA.Larry Davidson, PhD, Associate Professor and Director, Yale Program for Recovery and Community Health, Yale University School of Medicine, Department of Psychiatry, Erector Square 6W, Suite IC, 319, Peck Street, New Haven, CT 06511, USA.     

Sustainability of healthcare improvement: what can we learn from learning theory?

ABSTRACT: BACKGROUND: Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement. METHODS: Forde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Forde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework. RESULTS: Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute. CONCLUSIONS: The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.     

Involving people with severe mental illness in evaluation and performance improvement

This article argues for the increased involvement of people with severe mental illness and consumers of other health and mental health services in evaluation and performance improvement in the organizations from which they receive services. Among other reasons, consumers can bring a different perspective to the selection of areas to evaluate, such involvement is consistent with some models of program evaluation, and the process of participation itself can be empowering to consumers. Based on a review of the literature and the experiences of a public psychiatric hospital in involving consumers in evaluation and performance improvement, the authors exemplify how mental health consumers can participate in each stage of the evaluation process, ranging from the initial stage of posing evaluation questions to the final stage of acting on evaluation findings. Next, challenges to consumer involvement are described. Guidelines are then offered for involving consumers of health and mental health services in evaluation and performance improvement.     

The good, the bad, and the severely mentally ill: Official and informal labels as organizational resources in community mental health services

Research on labeling mental illness has focused relatively little attention on practical organizational concerns in the process of labeling in community mental health services. This paper examines this issue through an ethnographic study of two multi-service community mental health services organizations for people labeled severely and persistently mentally ill in the Midwest United States. The findings show that the labeling process is structured by cultural and policy environments in which mental health services are able to provide resources otherwise difficult to obtain. Within organizations, official labels can be applied for reasons other than clinical practice; they channel resources to both organizations and clients. Informal organizational labels regarding client mental illness are not tethered to the bureaucratic apparatus granting access to and paying for services. Instead, they reflect workers' real assessments of clients, which can differ from official ones. These informal labels determine how organizations deal with clients when rules and routines are violated.     

'They don't treat you like a virus': youth-friendly lessons from the Australian National Youth Mental Health Foundation

Young people experience high rates of mental health problems, but very few access professional mental health support. To address the barriers young people face in accessing mental health services, there is growing recognition of the importance of ensuring services are youth-friendly. Indeed, almost a decade ago, the World Health Organisation developed a youth-friendly framework for services to apply. Yet, this framework has rarely been evaluated against health initiatives for young people. This article begins to address this gap. Using 168 semi-structured, qualitative interviews with young service users, this paper explores the extent to which the Australian National Youth Mental Health Foundation, also called headspace, applied the WHO's youth-friendly framework which emphasises accessibility, acceptability and appropriateness (AAA). It argues that headspace was largely successful in implementing an AAA youth-friendly service and provides evidence of the importance of tailoring services to ensure they are accessible, acceptable and appropriate for young people. However, it also raises questions about what youth-friendly service provision means for different young people at different times. The findings suggest that youth friendliness should be applied across different stages of interaction (at initial engagement and in the ongoing relationship between patient and clinician) and at different levels (the environment the care is provided in, within policies and procedures and within and between relationships from receptionists to clinicians).     

A survey of mental health service coverage within health maintenance organizations.

This 1978 national survey of all operating Health Maintenance Organizations (HMOs) provided information on the current status of mental health services utilization and service coverage within HMOs. It achieved a 68 per cent response rate. Approximately 90 per cent (108) of the HMOs offered mental health services through basic or supplemental coverage plans; HMO organization characteristics reflected relative heterogeneity; the mean monthly costs for basic health plan coverage (physical and mental health services) were $33.85 (for individuals) and $95.15 (for families); HMOs reported lower physical and mental health hospital utilization and higher ambulatory utilization when compared to more traditional forms of health insurance coverage. The present coverage and uitlization of mental health services within HMOs reflect greater variability of benefits and utilization within HMOs. There is need for further studies of mental health utilization in relation to organizational structure and delivery pattern relationships within HMOs.     

Sales force development in health services organizations; a boundary spanning perspective

Sales force development is of growing importance to HSOs in their increasingly competitive and heterogenous health care markets. There is always some danger that, under such circumstances, strategies new to HSOs will be adopted without sufficient attention to how they function and how they might best be integrated into the organization's overall mission. The sales force is becoming an important part of administration in the modern HSO. Ensuring that sales personnel effectively meet the needs of clients and of all relevant units of their HSO calls for attention to a number of concerns raised in organization-environment theory. Concepts from the literature on organizational boundaries and boundary spanning used here organize and illuminate major issues in sales force development. The approach taken is one which underscores the importance of these issues, illustrates some possible responses, and encourages HSO administrators to reflect on organizational implications of sales force development. The perspective offered provides a base for more detailed design considerations in planning and implementing a sales force.     

Evidence-based HIV prevention in community settings: provider perspectives on evidence and effectiveness

As part of the efforts to expand evidence-based practice (EBP) in HIV prevention at the community level, the Centers for Disease Control and Prevention (CDC) created the Diffusion of Effective Behavioral Interventions (DEBI) program. Frontline service providers, who are charged with adopting and implementing these interventions, however, have resisted and criticized the dissemination of evidence-based HIV prevention interventions. Their failure to implement the interventions with fidelity and abandonment of plans to implement interventions in which they were trained have often been discussed from the framework of ‘capacity-building’. This framework points to ‘deficits’ within community-based organizations (CBOs) that impede the uptake of EBP. This article presents the perspective of 22 frontline service providers from CBOs (n?=?8) in a Midwestern state on their experiences with the DEBI program, and illustrates the reasons providers may not implement EBP. Analysis of interview responses reveals that providers cite diverse reasons – beyond organizational capacity – for lack of implementation with fidelity. Specifically, they offer critiques of the DEBI program based on the models of evidence of effectiveness on which it is based.     

Cost of employee assistance programs: Comparison of national estimates from 1993 and 1995

The cost and financing of mental health services is gaining increasing importance with the spread of managed care and cost-cutting measures throughout the health care system. The delivery of mental health services through structured employee assistance programs (EAPs) could be undermined by revised health insurance contracts and cutbacks in employer-provided benefits at the workplace. This study uses two recently completed national surveys of EAPs to estimate the costs of providing EAP services during 1993 and 1995. EAP costs are determined by program type, worksite size, industry, and region. In addition, information on program services is reported to determine the most common types and categories of services and whether service delivery changes have occurred between 1993 and 1995. The results of this study will be useful to EAP managers, mental health administrators, and mental health services researchers who are interested in the delivery and costs of EAP services.     

The progressive impact of psychological climate: A prognosis of health care providers’ subjective powerlessness in reform legislation

This study explores the impact of psychological climate variables on the perceived powerlessness of health care providers with regard to their contribution in reform initiatives. It is proposed that perceptions of powerlessness in intra‐organizational settings can and do extend to subjective powerlessness in the sociopolitical arena. A conceptual framework for the theoretical arguments is provided. The hypotheses were tested on survey data from health care providers employed in a major US primary metropolitan statistical area. Several highly significant relationships were observed. Since the actions of health care administrators are primarily responsible for shaping their institutions’ psychological climate, recommendations regarding how administrators can foster psychological climates that induce more provider involvement in reform are offered.     

Financing mental health services in low- and middle-income countries

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.     

Is it time to abandon care planning in mental health services? A qualitative study exploring the views of professionals,service users and carers

Background

It has been established that mental health‐care planning does not adequately respond to the needs of those accessing services. Understanding the reasons for this and identifying whose needs care plans serve requires an exploration of the perspectives of service users, carers and professionals within the wider organizational context.

Objective

To explore the current operationalization of care planning and perceptions of its function within mental health services from the perspectives of multiple stakeholders.

Settings and participants

Participants included 21 mental health professionals, 29 service users and 4 carers from seven Mental Health Trusts in England. All participants had experience of care planning processes within secondary mental health‐care services.

Methods

Fifty‐four semi‐structured interviews were conducted with participants and analysed utilizing a qualitative framework approach.

Findings

Care plans and care planning were characterized by a failure to meet the complexity of mental health needs, and care planning processes were seen to prioritize organizational agendas and risk prevention which distanced care planning from the everyday lives of service users.

Discussion and conclusions

Care planning is recognized, embedded and well established in the practices of mental health professionals and service users. However, it is considered too superficial and mainly irrelevant to users for managing mental health in their everyday lives. Those responsible for the planning and delivery of mental health services should consider ways to increase the relevance of care planning to the everyday lives of service users including separating risk from holistic needs assessment, using support aids and utilizing a peer workforce in this regard.