Long-term Psychiatric Care Research Articles

The Preservation of Order: The Use of Common Approach Among Staff Toward Clients in Long-Term Psychiatric Care

The authors performed this grounded theory study to gain a deeper understanding of the kinds of social processes that lead to a need among psychiatric nursing staff to reach a common approach on how to act toward individual clients in long-term psychiatric care. They present a theory about the development of such common approaches among staff. The main findings were that in psychiatric group dwellings, when the internal order is perceived as having been disturbed, the staff preserve or restore the internal order by formulating and reaching a common approach. The staff negotiated with each other to achieve an agreement on how to act and behave toward the individual client. The authors isolate and describe different types of order-disturbing incidents and the common approaches taken by the staff in dealing with them. However, their data also show that staff often had difficulties in maintaining a common approach over time.

Injuries and Assaults in a Long-Term Psychiatric Care Facility: An Epidemiologic Study

The objectives of this study were to document the high rates of acute injuries and physical assaults among nurses and certified nursing assistants working in long-term psychiatric care facilities and to identify risk factors for assaults and injuries to inform prevention strategies. A mixed-design cohort study was conducted. Acute injury and physical assault data were obtained from administrative records. Using staff rosters and schedule records, incidence rates were calculated by job title, gender, shift, and floor. Rates were also reported by severity, body part, type, and nature. Targeted interviews with staff members provided measures of physical lifting and resident combativeness. Injury rates were calculated by degree of lifting and assault rates were calculated by degree of resident combativeness. Overall rates of injuries (55.6 per 100 person-years) and assaults (67.3 per 100 person-years) were substantially higher than expected. Predictably, injuries were associated with resident lifting and assaults were associated with contact with combative residents. A higher risk of assault was found among women and higher risks of injury and assault were observed among full-time employees compared to per diem or pool agency workers. In addition, weekend shifts were found to have a higher rate of injuries and a lower rate of assaults than weekday shifts. In similar long-term care facilities with psychiatric populations, efforts should be made to reduce lifting and avoid circumstances that agitate residents. Work organization factors should be taken into consideration when developing interventions.

Interception of potential adverse drug events in long‐term psychiatric care units

The interception of medication errors is required for patient safety. The aim of the present study was to clarify factors associated with the interception of potential adverse drug events in long-term psychiatric care units. A survey was conducted of medication-related errors in 132 Japanese long-term psychiatric care units for 2 months using an incident reporting system. The relationship was analyzed between the reported potential adverse drug events and the characteristics of the units and the staff, as well as those of the patients involved. A multivariate logistic regression analysis was performed with environmental, organizational, and human factors as independent variables to predict the interception of potential adverse drug events. Of the 221 reported incidents, 55 (24.9%) were intercepted before reaching patients. The following patient groups were significantly associated with the failure to intercept potential adverse drug events: patients receiving a relatively large number of tablets, patients with relatively frequent admissions, and patients exposed to a relatively high patient-staff ratio in the evening. In contrast, patients with a diagnosis of schizophrenia were significantly associated with an increased possibility of interception. To intercept more potential adverse drug events, simpler prescriptions are crucial. To improve the current situation, organizational efforts, such as increasing staff in the evening, and educating the staff about medications, will be required, as well as improvements in the medications themselves.

Assembly Members Tackle Wide-Ranging Agenda

Assembly Members Tackle Wide-Ranging Agenda

The prevalence of dyslexia and AD/HD in a sample of forensic psychiatric rapists

The prevalence of dyslexia and attention deficit/hyperactivity disorder (AD/HD) (DSM-IV) is markedly increased among those who are sentenced for criminal offences. The aim of the study was to identify developmental disabilities, dyslexia and AD/HD among severely disturbed men in forensic psychiatric care, and to study the co-occurrence of such disabilities, with the objective to discuss the importance of the diagnoses in forensic psychiatry. The participants were 10 males who had committed rape on adult women, and included two murder-rapists, one of which had murdered more than one victim (i.e. a serial murderer). All had been assigned to special long-term forensic psychiatric care, based predominantly on a psychodynamic ground. In order to be identified as having dyslexia, a participant's performance on at least three out of four tests of academic skills had to be markedly below the expected level (more than two stanine steps), given the participant's non-verbal intellectual capacity and considering the length of his education. AD/HD was investigated by studying the participants’ forensic psychiatric files and by a clinical interview. Seven of the 10 participants met the DSM-IV criteria for dyslexia, and six of them met the DSM-IV criteria for AD/HD. Four participants had AD/HD and dyslexia, three had AD/HD but no dyslexia, and two had dyslexia but no AD/HD. Only one participant had neither dyslexia nor AD/HD. The participants with dyslexia performed well in tests assessing non-verbal reasoning, visuo-spatial capacity and visual memory. Although the generalization of the results from 10 rapists is severely limited, the results indicate the importance of assessing dyslexia as well as AD/HD in people who are admitted for forensic psychiatric assessment. The lack of correct diagnoses may negatively influence the choice of appropriate forensic psychiatric care. Early assessment of those disorders might have a positive influence on the psychological development and socialization process in people with dyslexia and/or AD/HD.

Residential facilities as the new scenario of long-term psychiatric care

Department of Mental Health, Viale Pepoli 5, 40123 Bologna, Italy Correspondence to Giovanni de Girolamo M.D., Department of Mental Health Viale Pepoli 5, 40123 Bologna, Italy Tel: +39-0516584204; fax: +39-0516584244; e-mail: [email protected] Abbreviations QOL: quality of life TAPS: Team for the Assessment of Psychiatric Services

States Find Creative Ways To Fund Public-Sector Care

Back to table of contents Previous article Next article Government NewsFull AccessStates Find Creative Ways To Fund Public-Sector CareKate MulliganKate MulliganSearch for more papers by this authorPublished Online:19 Sep 2003https://doi.org/10.1176/pn.38.18.0010Advocates often cite the Institutions for Mental Illness (IMD) exclusion as an example of legislation that works to hamper efforts to serve people with mental illness.The IMD exclusion prohibits Medicaid reimbursement for inpatient care provided to individuals between the ages of 22 and 64 if the care is delivered in a psychiatric institution that contains 16 or more patient beds. It was intended to support the policy that states, rather than the federal government, have responsibility for funding long-term psychiatric care, particularly for adults.Representatives of major mental health organizations, such as the National Alliance for the Mentally Ill, told members of President Bush’s New Freedom Commission on Mental Health last year that the IMD exclusion has outlived any usefulness and serves to fragment the delivery of mental health care.A 2003 report from the Substance Abuse and Mental Health Services Administration titled “Medicaid Financing of State and County Psychiatric Hospitals” suggests, however, that state officials and hospital administrators have found various other sources of Medicaid revenue that soften—at least, temporarily—the potentially harsh consequences of the exclusion.In fact, researchers from Mathematica Policy Research Inc. estimate that in 2001 $2.6 billion in Medicaid funds were paid on behalf of public psychiatric hospitals in the United States. The figure represents approximately one-third of total operating costs for those institutions.Approximately $2.2 billion of those funds came from Medicaid’s Disproportionate Share Hospital (DSH) program. The program provides payments to hospitals that care for a large volume of poor patients. States have discretion in determining hospitals’ eligibility for DSH payments. Hospitals must receive DSH payments if their low-income utilization exceeds 25 percent and may receive designation if the Medicaid utilization rate is at least 1 percent of total bed days.Like other programs funded through Medicaid, federal DSH payments must be matched with state funds according to a formula that reflects the wealth of the state.Report authors included more detailed analysis of the role and sources of funding for public psychiatric hospitals in Arkansas, California, Iowa, Maryland, and New Jersey.There is considerable variation among the states in terms of their aggressiveness in claiming DSH funds and their methods of distributing them. In Maryland and New Jersey, for example, state psychiatric hospitals are totally funded by state appropriations. In Maryland, DSH funds go to the state general fund rather than to the hospitals. In New Jersey, DSH funds are earmarked for charity care and hospital-relief funds.Not surprisingly, given the otherwise limited resources available for public psychiatric hospitals, the size of the DSH program has increased dramatically. Expenses rose from a total of $1.4 billion in payments with six participating states in 1990 to $15.9 billion in 2001 with 47 states and the District of Columbia as participants.The program cannot be viewed, however, as a long-term funding solution for long-term psychiatric care. Congress has acted to curb the growth in the DSH program. Members limited expenditures to 1992 levels for “high DSH” states and in 1997 capped spending on IMDs at Fiscal 1995 levels and also set standards that would result in a declining percentage of DSH funds going to IMDs.Medicaid funds also can become available for IMDs through savings that states generate from Medicaid managed care programs and through the use of Medicaid waivers that allow the states to add optional services or populations if they offset the additional costs by Medicaid savings. Those sources of funds are threatened by the state-budget crises that have led to cuts in Medicaid enrollees and benefits.“The role of public psychiatric hospitals is changing constantly,” concluded the report’s executive summary. “States have worked since the 1950s to move large numbers of patients out of these facilities into community-based treatment settings. The challenges faced by state and county psychiatric hospitals are substantial and are likely to affect future Medicaid financing strategies pursued by the hospitals themselves or on their behalf.”“Medicaid Financing of State and County Psychiatric Hospitals” is posted on the Web at www.mentalhealth.org/publications/allpubs/SMA03-3830/default.asp. ▪ ISSUES NewArchived

Mortality after discharge from long-term psychiatric care in Scotland, 1977-94: a retrospective cohort study.

BackgroundRecent United Kingdom strategies focus on preventable suicide deaths in former psychiatric in-patients, but natural causes of death, accidents and homicide may also be important. This study was intended to find the relative importance of natural and unnatural causes of death in people discharged from long-term psychiatric care in Scotland in 1977 –1994.MethodsPeople discharged alive from psychiatric hospitals in Scotland in 1977 – 94 after a stay of one year or longer were identified using routine hospital records. Computer record linkage was used to link hospital discharges to subsequent death records. Mortality was described using a person-years analysis, and compared to the general population rates.Results6,776 people were discharged in the time period. 1,994 people (29%) died by the end of follow-up, 732 more deaths than expected. Deaths from suicide, homicide, accident and undetermined cause were increased, but accounted for only 197 of the excess deaths. Deaths from respiratory disease were four times higher than expected, and deaths from other causes, including cardiovascular disease, were also elevated.ConclusionSuicide is an important cause of preventable mortality, but natural causes account for more excess deaths. Prevention activities should not focus only on unnatural causes of death.

The experience of motherhood in women with severe and enduring mental illness.

This study considers the experience of motherhood of women who are patients of the rehabilitation services in Leicester. Data were collected from case notes, by semi-structured interviews with all women identified as mothers, and by enquiries with key workers on demographic characteristics, number of children, contact with and separations from these children, and other relationships. Fifty-eight women had 122 children. Of the mothers, 68 % were permanently separated from at least one child before the age of 18 years, and often had little or no subsequent contact with them. There was also attrition of other important relationships. There was scanty documentation about these issues in medical notes. Many women in long-term psychiatric care have experienced multiple losses. Clinicians should be mindful of this.

Are needs and satisfaction of care associated with quality of life? An epidemiological survey among the severely mentally ill in the Netherlands.

Is the quality of life of severe mentally ill patients influenced by the intensity of the care provided, their satisfaction with services and/or the amount of unmet needs? The interrelatedness of these three outcome measures was investigated in a sample of 101 patients dependent on long-term psychiatric care in the Northeast of the Netherlands. Instruments used were the Camberwell Assessment of Needs, the Verona Service Satisfaction Schedule and a health related quality of life instrument, the EuroQoL. Quality of life was unrelated to satisfaction with services but was strongly associated with unmet needs in the area of mental and physical health, and of rehabilitation. Quality of life decreased as needs increased. Needs were also strongly related to diagnosis and cognitive functioning. Furthermore, more intensive care settings were provided as needs increased. Demographic, diagnostic and treatment variables did not explain much extra variance in quality of life. Despite the availability of various services in the region there was a lack of tailor made care which took into account specific unmet needs with regard to information, social contacts, and daily activities.

Long-Term Psychiatric Care Service and Coordination Gaps in Michigan's Publicly Funded Mental Health System

Abstract A multi-party planning effort examined long-term psychiatric care issues confronting Michigan's publicly funded mental health system. It was found that the state's Community Mental Health network primarily serves people experiencing mental illness, yet spends less than 45% of its funds on such individuals. The most pressing long-term psychiatric service gaps in Michigan were identified as: continuous inpatient care; housing; and wraparound service for minors. The greatest coordination difficulties involved mental health collaboration with: primary care; justice systems; substance abuse services; and schools. Recommendations were developed and advanced for dealing with the various gaps and other key issues.

Service innovations: a service for the homeless with mental illness in Aberdeen

Aims and MethodTo evaluate the first 3 years of a newly developed service for the homeless mentally ill in Aberdeen. All 86 referrals to the service between 1996 and 1999 were reviewed.ResultsThe majority of referrals came from social care staff and self-referrals.Half were diagnosed as having severe and enduring mental illness and of these one-quarter (11 cases) were engaged in long-term psychiatric care. A total of 744 in-patient days were required, only one admission was a compulsory detention.Clinical ImplicationsIt has proven possible to identify and engage with a number of homeless individuals who have untreated serious mental illness by setting up a small dedicated service that has close links with an established adult mental health team and which establishes close working relationships with colleagues in social care settings.

Oral health status of psychiatric patients.

Many patients suffering from long-term psychiatric illness are on medication for long periods. These medications frequently cause xerostomia leading to an increased risk of caries, gingivitis, periodontitis and stomatitis. Oral hygiene is therefore of the utmost importance for these patients. Nurses interact with patients on a daily basis, and therefore they are the psychiatric caregivers of choice to support these patients. The main aim of this study was to describe the oral health status of patients in short-term and long-term psychiatric care by means of oral assessment. A second aim was to discover whether the assessment guide used could distinguish any differences between these two groups. A modified version of the Oral Assessment Guide (OAG) developed by Eilers et al. (1988) was used. In addition, new items/categories were developed, forming the Oral Assessment Guide for Psychiatric Care (OAG-PC). A total of 57 patients in psychiatric care, short-term (n = 32) and long-term (n = 25), were assessed by the OAG-PC. Patients in long-term psychiatric care had significantly higher scores on the total OAG-PC compared with those in short-term psychiatric care, indicating a worse oral health status. Statistically significant differences were also found in relation to the following OAG-PC categories: odour from the mouth, mucous membranes, gums, teeth or dentures, calculus on teeth and appearance of teeth. Further research should be focused on the difficulties for nurses in approaching their patients in order to perform oral care and on evaluating the effect of teaching and training psychiatric nurses in oral care, preferably with the assistance of the OAG-PC. This assessment guide may thereby also be valuable for nurses' documentation in estimating, planning, implementing and evaluating their psychiatric patients' oral care needs.

State health care reform: conflicting perspectives on consolidating long-term psychiatric inpatient care at a single state hospital.

State health care reform: conflicting perspectives on consolidating long-term psychiatric inpatient care at a single state hospital.

Nursing Interventions in Crisis-oriented and Long-term Psychiatric Home Care

Nursing Interventions in Crisis-oriented and Long-term Psychiatric Home Care

Nursing Interventions in Crisis‐oriented and Long‐term Psychiatric Home Care

Psychiatric nurses in The Netherlands are moving out of residential mental health institutions and are pioneering home care for the acutely and chronically mentally ill. The purpose of this study was to identify the interventions nurses currently use and to describe the differences between crisis-oriented and long-term psychiatric home care. Data was collected of 159 nursing care plans from four participating crisis-oriented and two long-term psychiatric home care teams. All stated nursing activities were identified and subsequently labelled and classified using the Nursing Intervention Classification (NIC). Results revealed that in both crisis-oriented and long-term psychiatric home care, nurses used a wide range of nursing interventions. Medication Management, Coping Assistance and Activity Therapy were the most frequently undertaken nursing interventions in both types of care. Within crisis-oriented care, Emotional Support and Self-esteem Enhancement dominated, whereas long-term care focused on Socialization Enhancement and Home Maintenance Assistance. The results will be used for further research and for standardization of nursing care plans within these categories of nursing practice.

Validation of the Adult Suicidal Ideation Questionnaire and the Reasons for Living Inventory in an adult psychiatric inpatient sample.

This study investigated the factor structure of the Adult Suicidal Ideation Questionnaire (ASIQ) and the Linehan Reasons for Living Inventory (LRFL) in a sample of 205 adult psychiatric inpatients. Confirmatory factor analyses provided moderate support for the construct validity of each instrument. Coefficient alphas for the ASIQ (.98) and LRFL (.93) were high. In addition, a range of different clinical cutoff points was derived for each instrument. Both instruments were also better than chance in differentiating between the suicide attempter and psychiartic control groups. High ASIQ and low LRFL scores were significantly associated with scores on selected Minnesota Multiphasic Personality Inventory-2 Content scales. The analyses also indicated that only the ASIQ added to the symptoms of hopelessness and negative affect in differentiating between the suicide attempter and psychiatric control groups. Results suggest that both instruments may be useful screening tests for suicidal behavior in psychiatric long-term care inpatient samples.

Frequency of recovery from anorexia nervosa of a cohort patients re-evaluated on a long-term basis following intensive care.

The need to treat the acute onset of anorexia nervosa in a specialty unit is well known, but nevertheless, even "clinically recovered" patients show a high rate of relapse. The aim of our study was to re-evaluate various clinical (hemoglobin, transferrin, insulin-like growth factor I, TSH, PRL, gonadotropins and 17 beta-estradiol) and psychiatric [semistructured interview, Eating Disorder Inventory (EDI) Test] parameters in 19 female anorexic patients hospitalized in our department from 1983 to 1993 (with a 9-year median prior to the present study) for the treatment of anorexia nervosa, and to compare these results with those of a previous follow-up performed on the same subjects in 1993. In the present evaluation, no significant variation was found among the clinical, nutritional and hormonal parameters when compared to those of the first follow-up in which all parameters had improved with the exception of the PRL levels, which were significantly low. Meanwhile, the percentage of patients with spontaneous menses increased significantly from 50% to 70%, while the number of patients on psychopharmacological therapy decreased significantly throughout the study. Furthermore the percentage of patients with altered (severe or mild) EDI profiles decreased to 50%. This study emphasizes the positive prognostic role of hospitalization and intensive care in a cohort of anorexic patients. The present study, in addition to demonstrating both a general maintenance of body weight acquired over the years, albeit in the lower normal range, and an increase in the percentage of patients with a regular menstrual cycle, also highlights the persistence of psychiatric abnormalities in a large number of patients, even in those diagnosed as "clinically recovered", thus suggesting the need for long-term psychiatric care.

The nursing process in crisis-oriented psychiatric home care.

Crisis-oriented psychiatric home care is a recent development in the Dutch mental health care system. Because of the difference between psychiatric care in the home and in the hospital, an action research project was initiated. This project was directed at the nursing process and the nurses' role and skills in psychiatric home care. The main goal of the project was to describe and to standardize nursing diagnoses and interventions used in crisis-oriented and long-term psychiatric home care. The development of supporting methods of assessment and intervention were also important aspects of this project. In this article a crisis-oriented psychiatric home care programme and the first developmental research activities within this programme are described. To support the nursing process, the development of a nursing record and an assessment-format, based on Gordon's Functional Health Patterns (FHP), took place. By means of content analysis of 61 nursing records, the most frequently stated nursing diagnoses, based upon the North American Nursing Diagnosis Association (NANDA) taxonomy, were identified. The psychiatric diagnostic categories of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) were also collected. The most common categories found were those of mood disorders and schizophrenia or psychotic disorders. Seventy-five per cent of the nursing diagnoses showed up within four FHP: role-relationship, coping-stress tolerance, self-perception/self-concept and activity-exercise. The nursing diagnosis of 'ineffective individual coping' was stated most frequently. This is not surprising because of the similarities in the definitions of this nursing diagnosis and the concept of 'crisis' to which the psychiatric home care programme is oriented. Further research activities will be focused on standardization of nursing diagnosis and the interventions that nurses undertake in this type of care.

Long-term psychiatric care in Papua New Guinea

Papua New Guinea is being forced to rapidly adjust to large changes with consequent effects on the mental well being of the population and mental health services. This paper describes my experiences and reflections on 14 months spent working as a psychiatrist between April 1991 and July 1992 in Papua New Guinea and describes Laloki Psychiatric Centre; the only long-stay psychiatric hospital in Papua New Guinea.