Integration of disaster mental health services with emergency medicine

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and follow-up; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.     

Adjusting for patient characteristics and selection effects in assessment of community mental health centers

OBJECTIVE: The objective of this study was to determine the effect of patient socioeconomic characteristics and center selection of patients on measured performance of community mental health centers. DATA SOURCE/STUDY SETTING: Data were taken from the administrative records of Indiana's public mental health system for 16,516 adults with severe, persistent mental illness treated in 30 community mental health centers. Center performance was compared using longitudinal information on patient functioning. METHODS: A mixed random-effects model that is suitable for fitting data with a hierarchical structure was used to assess relative performance. PRINCIPAL FINDINGS: Measured performance was found to depend significantly on patient education, income, marital status, race, ethnicity, and baseline health (P<0.05). Results also indicated centers that were more successful at maintaining patients in treatment were unfairly underranked by unadjusted performance scores. CONCLUSIONS: Both the socioeconomic background of patients and patient selection by centers impact apparent performance in community mental health care. If observational data are used to evaluate community-based providers, analysts might need to account for both effects to ensure comparisons of relative performance are accurate.     

Linkages between community mental health centers and public mental hospitals

Directors of community mental health centers and superintendents of public mental health hospitals in one state were surveyed to gather data on interagency linkages. Implementation of affiliation agreements, exchange of staff training, and exchange of patient information were investigated. Affiliation agreements tended to be implemented with little difficulty and there was more interagency cooperation than that reported in earlier research. However, exchange of training and staff were still areas of minimal interaction. Geographic proximity was found to have a positive influence and competition a negative influence on cooperation. Further attempts at interagency linkages in the interest of continuity of patient care are recommended.     

Managed mental health care: problems and possibilities

Case management has become an established organizational approach to mental health care. However, a recent development of case management, known as 'managed care' has received only limited attention in the UK and this has been confined to acute medical or surgical hospital care. The potential of managed care as applied to mental health care is uncertain. This paper clarifies the nature of managed care and discusses its relevance to mental health care, in particular to the care of people suffering from schizophrenia. The high incidence and heavy resource demands of this user group makes these people an ideal focus for managed care. However, there are conceptual and practical problems hindering its development and implementation, including: the variability and unpredictability of the disease process of schizophrenia; challenges of outcome measurement; and problems relating to the current organization of mental health care.     

Clinical and economic impact of newer versus older antipsychotic medications in a community mental health center.

This pilot study was conducted to compare both the clinical effectiveness and the treatment costs of newer (atypical) antipsychotic medications (clozapine and risperidone) with those of older (classic) neuroleptic medications (chlorpromazine and haloperidol) for psychosis in a community mental health care setting. The study used a retrospective, uncontrolled, open, nonrandomized, within-subjects design and relied on medical records as a data source for 37 clients. All clients received older antipsychotics for at least 1 year, newer antipsychotics for a transition period of 3 months, and the newer agents for at least an additional year. The newer antipsychotic medications were more effective and less costly (total cost of care, $3000 less per client per year [1997 dollars]) than the older medications. Effect-size estimates for the measured variables provide a guide for future research into the cost-effectiveness of these newer medications within the community mental health care setting. These findings can provide policy makers with guidance on treating people with major mental disorders in the most effective and efficient manner. Because of limited budgets, community mental health centers making the investment in newer, more expensive medications to improve client outcomes have to maintain the same or lower total cost of care. Results of the current study suggest that short-term investment in the newer medications by community mental health centers offers superior clinical effectiveness and lower long-term overall cost of care.     

Serious mental illness and smoking cessation

Persons with serious mental illness (SMI) are faced with substantial challenges to their health. This population is two to three times more likely to smoke cigarettes than persons who do not suffer from mental illness. In particular, young adults are at high risk for vulnerability to both SMI and cigarette smoking. Although there are proven methods for smoking cessation, both pharmacologic and non-pharmacologic interventions show limited usefulness for SMI who smoke. Alternative health care options as well as support groups and physical exercise are discussed as methods that may be useful in smoking cessation. Finally, integration of smoking cessation programming into existing mental health treatment services may offer the greatest opportunity for client success.     

Community mental health care in Botswana: approaches and opportunities

AIM: The purpose of this article is to provide an insight into the developmental trends in community mental health care in Botswana. Different approaches are discussed and the opportunities that have emanated from them. BACKGROUND: Care of the mentally ill in Botswana is provided at different levels of coverage and sophistication. There is a single mental hospital in the country. Attached to the district hospitals are psychiatric outpatient clinics run by psychiatric nurses and a psychiatrist who visits them on monthly basis. Mental health care in Botswana has gone through a paradigm shift, from the prepenal years, penal years and institutional to community based care, which reflects a philosophy of citizen involvement and collaboration. CONCLUSION: Several approaches have been utilized in the development of community mental health care. However, difficulties and challenges still exist in the provision of community mental health care.     

Infant mental health in intensive care: Laying a foundation for social,emotional and mental health outcomes through regulation,relationships and reflection

Infants and their families who begin their lives in intensive care often experience short and long term behavioral, socioemotional and mental health challenges that often follow them into adulthood. Utilization of evidence-based infant mental health principles, approaches and strategies in the neonatal intensive care unit can contribute to the promotion of optimal outcomes for babies and their parents. In order to integrate mental health best practices into intensive care settings, an emphasis on infant and family regulation, optimal nurturing relationships and reflective practice is offered. Using a parallel process, similar strategies in support of intensive care professionals in their provision of appropriate mental health supports to babies and families is essential.     

Contemplating, caring, coping, conversing: a model for promoting mental wellness in later life

This article is based on the premise that mental wellness for older adults can be promoted through communication and presents a model drawing on the constructs of contemplating, caring, coping, and conversing. The importance of interpersonal communication processes in the care of older adults and some barriers to communication and mental wellness are briefly reviewed. This article challenges nurses to develop awareness of their own caregiving styles and communication processes, and to assist others (e.g., family caregivers, care receivers) to communicate and interact more effectively to advance mental wellness for older adults.     

Transcultural nursing: the relationship between individualist ideology and individualized mental health care

This article attempts to clarify and underpin the view that individualized mental health nursing is culture biased and politically instrumental, adding weight to the transcultural argument that mental health care should be more culture sensitive than is often the case within conventional UK settings. It examines the political history of individualist ideology, and then uses social conflict theory to explore the potentially counter-therapeutic relationship of individualism and individualized nursing care in the UK mental health sector. The article challenges the widespread idea that individualized mental health nursing is 'liberal', 'democratic', 'holistic' and 'scientific', and in so doing extends the transcultural agenda to large scale infracultural differences within the UK population. It also explores the potential for policy change towards a more pluralistic service, and outlines some of the practical steps which may be taken to access alternative care approaches. It is a power analysis, which may be of transferable value to nurses in mental health care inpatient units where conventional individualized approaches are failing to reintegrate service users into the community. A glossary of terms is presented at the end of this article.     

Registered nurses' experiences of interaction with patients with mental health challenges in medical wards in Johannesburg

poggenpoel m. , myburgh c.p.h. & morare m.n. (2011) Journal of Nursing Management 19, 950–958 Registered nurses’ experiences of interaction with patients with mental health challenges in medical wards in Johannesburg Aim The aims of this research were to explore and describe registered nurses’ experiences of interacting with patients with mental health challenges in the medical wards of a public hospital in Johannesburg. Background Nurses are the major providers of hospital care and have become an important resource in the delivery of mental health care to patients with mental health challenges. However, the attitude and ability of many nurses in providing this care have been shown to be poor. Method In-depth phenomenological interviews were conducted with eight female registered nurses working in four medical wards where they interact with patients with mental health challenges. Results From the findings it is clear that registered nurses experienced frustration, unhappiness, fear and perception of danger when interacting with patients with mental health challenges in their wards. This could be attributed to a lack of knowledge and skills in mental health. Conclusion Registered nurses have negative experiences with interaction with patients with mental health challenges in medical wards because of a lack of knowledge and skills in mental health. Implications for nursing management Ward managers can facilitate the psychological empowerment of registered nurses.     

Revisiting Balint's innovation: enhancing capacity in collaborative mental health care

Abstract

Interprofessional collaboration is increasingly recognized as a key response to the challenges associated with complex mental health issues in community primary-care settings. Relatively few practice models, however, provide an orientation and a structure that combines quality patient care, professional development, and the building of community capacity. A psychodynamic tradition of supervision and collaboration, an approach known as the Balint model, holds considerable potential to bring this orientation to collaborative primary care and mental health teams. As a consultation group, the Balint approach brings participants' attention to subtle emotional–interpersonal phenomena such as the provider–patient relationship, the presentation of illness, and the experiences of patients and team members. We introduce and provide an overview of the Balint group model, including several concepts proposed by Balint to illuminate the emotional and relational complexities of providing mental health care in a collaborative primary-care setting. The context of our discussion is the implementation of a modified Balint group approach within a Canadian collaborative mental health Care (CMHC) program. We also discuss how an interprofessional application of this approach can enhance patient care, contribute to care providers' professional development, and build community capacity.     

Progression of the mental health nurse practitioner role in Australia

The guiding principle of health care is to serve the needs of the public. Healthcare services are therefore required to be increasingly flexible and open to new approaches to meet changing demands. They must also adjust and expand as new challenges are presented. Public awareness of mental health issues and the current demands placed on health services for access to affordable and appropriate mental health care have never been so great. The introduction of nurse practitioners (NPs) in Australia is a proud and long-anticipated moment for the discipline of nursing. However, a major challenge for the introduction of NPs in Australia will be to reassure medical colleagues, allied health professionals and the public that NPs are able to deliver high-quality primary care. This paper elaborates on the progress of the mental health NP role in Australia. Attention is centred on the characteristics the mental health NP role, the maintenance of professional competency to practise at an advanced clinical level, and the prospects and potential significance of NPs for mental health nursing practice. The nurse-led clinic, implemented through the process of consultation and systematic evaluation, is identified as an avenue for the extension of mental health NP practice in the delivery of autonomous primary care.     

Developing resilient children and families when parents have mental illness: a family-focused approach

There is substantial evidence supporting the need for effective intervention for children and families living with parental mental illness. However, translation of this knowledge into mental health workforce practice remains variable, with a range of clinical practices and models of care evident. Nurses, who constitute the majority of the mental health workforce, are in prime positions to support children and families and provide preventative measures, identify those at risk, and intervene early. In this paper, we provide a framework for practice for nurses working with consumer parents. We contend that traditional models of nursing practice concentrating on the consumer are insufficient in meeting the needs of children and families living with parental mental illness. A focus on families needs to be core business for mental health nurses. A family-focused approach can be used to prevent problems for children and their families, and identify their strengths as well as vulnerabilities. Family-focused care is a useful framework from which to support families and address the challenges that might arise from parental mental illness, and to build individual and family resilience.     

The challenges of mental health care reform for contemporary mental health nursing practice: delivery of nursing care

This ethnographic account of mental health nursing in a 22-bed acute inpatient facility in New South Wales, Australia, uncovered cultural meaning and cultural realities associated with the delivery of nursing care within the context of current challenges, demands, and influences brought about by service reforms. The findings demonstrate that mental health nurses have been responsive to changes brought about by the reforms. The ability of nurses to readily identify service gaps in their everyday practice provides them with the opportunity to develop strategies to respond to workplace challenges. As such, findings of the study contribute to current discussions concerning acute inpatient mental health nursing practice.     

Kennedy Axis V: Clinimetric properties assessed by mental health nurses

The Kennedy Axis V is a routine outcome measurement instrument which can assist the assessment of the short‐term risk for violence and other adverse patient outcomes. The purpose of this study was to evaluate the interrater reliability and clinical utility of the instrument when used by mental health nurses in daily care of patients with mental illness. This cross‐sectional study was conducted in inpatient and outpatient adult psychiatric care units and in one adolescent inpatient unit at a university hospital in the Netherlands. Interrater reliability was measured based on the independent scores of two different nurses for the same patients. The clinical utility of the instrument was evaluated by means of a clinical utility questionnaire. To gain a deeper understanding of rating difficulties at the adolescent unit, additional data were collected in two focus group interviews. The overall results revealed a substantial level of agreement between nurses (intraclass correlation coefficient and Pearson 0.79). Some rating challenges were identified, including difficulties with scoring the instrument and using tailor‐made interventions related to the scores. These challenges can be resolved using refined training and implementation strategies. When the Kennedy Axis V is accompanied by a solid implementation strategy in adult mental health care, the instrument can be used for short‐term risk assessment and thereby contribute in efforts to reduce violence, suicide, self‐harm, severe self‐neglect, and enhanced objectivity in clinical decision‐making.     

Learning from the world of mental health care: nursing students' narratives

This narrative study describes the substance of nursing students' learning in the area of mental health and their responses to the challenges of working in the psychiatric field. The data consisted of 39 critical incidents written by 20 Finnish second-year nursing students during their 5-week mental health placement. The narrative analysis method was used in the data analysis and the configuration of three consistent learning storylines: self-awareness and self-esteem, the nurse-patient relationship and mental health care methods. The three storylines characterized the essence of the students' learning and their responses to the challenges of the psychiatric field during the placement. The students were actively exposed to complicated care situations and patient encounters in which they had to face their own emotions and test coping skills. It seems that the critical incident technique stimulated students' narrative skills and possibly sensitized them for listening at the stories of their future patients.     

Mental Health Status of Women in Jordan: A Comparative Study between Attendees of Governmental and UN Relief and Works Agency's Health Care Centers

This study aimed at investigating differences in mental health problems between attendees of governmental and United Nations Relief and Works Agency for Palestine Refugees health care centers in Jordan. Further, predictors of mental health problems based on women's demographic profile were investigated. A convenience sample of 620 women attending governmental and United Nations Relief and Works Agency for Palestine Refugees health care centers in Jordan was recruited for this purpose. Independent samples t-tests were used to identify differences in mental health, and multiple linear regression was implemented to identify significant predictors of women's mental health problems. Results indicated an absence of significant differences in mental health problems between attendees of the two types of health care centers. Further, among the demographic indicators that were tested, income, spousal violence, and general health were the predictors of at least three different mental health problems in women. This study highlights opportunities for health professionals to decrease women's propensity for mental health problems by addressing these factors when treating women attending primary care centers in different Jordanian towns, villages, and refugee camps.     

Managing care for mental illness: paradox and pitfalls

Historically mental health has been separated from physical health care, and within mental health there have been largely separate public and private systems. A managed care approach now offers the potential of integrating and rationalizing mental health care. Counihan et al. and Stelovich represent the historical forces of mental health and health care, playing out as the two key models of managed care: the carve-out and the integrated model. However, the advent of managed care in today's health care system also presents significant dangers, particularly for vulnerable populations such as adults and children with severe and longterm mental disorders.     

Improving mental health care in general hospitals

The mental health needs of older people being cared for within general hospitals and other acute healthcare settings has been specifically identified as a priority for improvement. Yet in reality little has changed. The Department of Health (DH) (2006) has highlighted how many challenges still exist in developing effective integrated care for this patient group and continues to respond with further centrally initiated policy documents. This article explores the relationship between policy and practice and highlights how, despite their importance, policy initiatives alone are unlikely to be enough to ensure the effective delivery of mental health care for older people in general hospitals.