Organization and interaction in psychiatric day centres

Setting up a community support team for the severely mentally ill

This article describes the process of setting up a community support team for the severely mentally ill, and the challenges this posed. As this method of service delivery has been infrequently described, it is hoped our experience may be instructive to others.

Mental health day centres

Aims and Method

Mental health day centres have been little researched. We carried out a 1-week census at the four day centres run by a London borough.

Results

The centres catered for a g roup with long-standing mental health problems, mostly under community mental health team care. A surprising number were suffering from physical ill health. They attended the centres primarily for social reasons or to participate in creative groups such as music and art.Very few were concurrently attending day hospitals.

Clinical Implications

Further work is essential to understand the distinction between NHS day hospitals and Social Services day centres in terms of utilisation and client group.This client group's needs, particularly for physical health care, require urgent attention.

Factors Influencing Attendance and Non-Attendance at a Day Unit

The purpose of this study was to look at the factors that determine attendance and non-attendance of long term psychiatrically ill clients at their activity programme in a day unit. Twenty-four clients were interviewed using an interview schedule. The areas covered included the information given to the client before attendance and on arrival, the reception given and the client's attitude towards staffing and the unit. The results showed two significant areas of difference between attenders and non-attenders: attenders knew who their keyworker was whereas non-attenders had little idea; and the non-attenders had not been convinced that the unit could be of benefit to them whereas the attenders saw the unit as being of value. A third area that seems significant to attenders and non-attenders is the perceived lack of information given at the time of their referral and before their first appointment at the unit. It would appear that the keyworker has an important role to play in helping to avoid non-attendance; in addition, the client must perceive the unit as having some value, otherwise non-attendance may follow.

A Structured Approach to Psychiatric Day Care

Although the value of specific treatment programmes in psychiatric day care is usually self-evident, the less overt benefits of attendance, such as relief from loneliness, are less obvious. A study is described which investigated the acceptability to patients of a structured approach to day care and whether less formal gains could be attributed to such an approach. Results of interviews with 35 ex-day-patients showed overwhelming support for a structured approach which, as a by-product, provided a number of incidental benefits. There was little support for the drop-in method of day care and a small group of patients who had difficulties with social interaction would have preferred treatment on a sessional basis.

Community and hospital residential care: a comparative evaluation

Objective: To compare the quality of care offered by a community hospital hostel and three hospital rehabilitation facilities (two traditional rehabilitation wards and an innovative normalisation unit) for people with longterm mental illnesses.

Method: Quality of care is assessed here on three different levels: those of Input using Programme Analysis of Service Systems; Assessment of Care Environments; Process using Ward Management Practices Questionnaire; Attitudes to Treatment Questionnaire; Outcome using Rehabilitation Evaluation Hall and Baker and the Life Experiences Checklist and resident and staff questionnaires. These measures cover a range of perspectives from staff to residents, and include both standardised assessments as well as specific schedules developed for the study.

Results: On Input measures, the community hospital hostel had the best scores on the Programme Analysis of Service Systems schedule, which measures the degree to which services meet predetermined normalisation criteria. On the Assessment of Care Environments it also scored favourably against other community facilities. Process measures showed no differences between units in terms of their management practices, all scoring well, but suggested some differences in staff attitudes. Staff in the community hospital hostel had the most medical approach to care, however this was accounted for by the scores of untrained staff. Qualified nurses had a more psychological approach to care. Finally on Output measures, residents in the community hospital hostel were found to be the most disabled on the REHAB scale. Despite this, they had a significantly better quality of life as assessed by the Life Experiences Checklist. Staff in the community hospital hostel had the clearest perceptions of their roles, though there were differences again in how qualified and unqualified staff perceived their work. Residents were generally satisfied with services, though residents in the community hospital hostel and in the hospital normalisation unit had the highest satisfaction levels.

Conclusion: The results of this comparative evaluation show that a high standard of care, equal to or surpassing some of the best hospital provision, can be provided in the community. This is despite the fact that the residents in the community hospital hostel were more disabled. Community patients' quality of life is better in a number of domains than their hospital counterparts and even patients initially reticent about the move into the community report higher levels of satisfaction, especially regarding their home environment. There-were interesting differences between trained and unqualified staff in the community hospital hostel. Trained staff had a more psychological view of patient care and felt more supported and appreciated by the team than their untrained colleagues. The implications of these findings for community residential care are discussed.

Psychiatric rehabilitation in community-based day centres: motivation and satisfaction

OBJECTIVE

This study investigated attendees' motivation and motives for participation in day centres and their satisfaction with the rehabilitation, while also addressing the influence of day centre orientation (work- or meeting-place orientation), gender and age.

METHODS

Ninety-three Swedish day centre attendees participated in a cross-sectional study and completed questionnaires about motivation, motives, and satisfaction with the rehabilitation. Data were analysed with non-parametric statistics.

RESULTS

The participants were highly motivated for going to the day centre and set clear goals for their rehabilitation. Female gender, but not age, was associated with stronger motivation. The strongest motives for going to the day centre were getting structure to the day and socializing. Attendees at work-oriented day centres more often expressed that they went there to get structure to the day and gain social status. Satisfaction with the rehabilitation was high, and the most common wishes for further opportunities concerned earning money and learning new things.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The rehabilitation largely seemed to meet the attendees' needs, but the findings indicated that further developments were desired, such as participation in work on the open market and more work-like occupations in the day centre, accompanied by some kind of remuneration.

The life situation of people with persistent mental illness visiting day centers: a comparative study

This study compared the life situation of visitors of day centers (DC) for people with mental illness (N = 93) with a comparison group (N = 82) in respect of sociodemographic and clinical characteristics, care consumption, well-being and everyday activities. The response rate was 49%, and those who declined are believed to be those with the most severe psychiatric disabilities. Most individuals were single (81%/78%) and few had children (12%/18%). The DC group had less education than the comparison group but had a friend more often. Although having their need for daily activities met, the DC group had greater unmet needs in respect of daily living in general. They less frequently reported having a psychosis and had fewer negative and more depressive symptoms. They got more housing support and general outpatient care, while the comparison group used specialized psychiatric care more frequently. The samples were equally satisfied with their care, health and well-being and found their everyday activities equally meaningful. The DC visitors formed a vulnerable group, by living single, having a low level of education and having unmet needs, and were at risk of not getting specialized psychiatric care.

Evaluation of the impact of a consultation in a secure setting

BACKGROUND

Organisational consultation is widespread in the National Health Service (NHS), but little is known about its impact.

AIMS

To evaluate the impact of a psychodynamically informed consultation to a high-security hospital ward.

METHOD

 This prospective study compared measures before and after the consultation with similarly timed measures on a comparison ward in the hospital, matched for patient characteristics, but not exposed to the consultation. The intention was to compare the consultation with 'treatment as usual', but the study became a comparison of interventions after a programme to facilitate staff-patient communication was instituted by management on the comparison ward. Measures included the Ward Atmosphere Scale (WAS) and an index of burnout. Interactions between staff and patients were observed and rated for content and quality.

RESULTS

 Most scales on two of three dimensions of the WAS improved on both wards, as did the quality of staff-patient contact. Change at the levels of behaviour and attitude strengthens confidence that a shift occurred in a positive direction.

CONCLUSIONS

 The overall importance of professional supportive attention to staff in such settings was established. Although there was little evidence here for a distinct advantage of one intervention style, the results were encouraging for the consultation, because ward atmosphere and staff-patient interaction were not a direct target for change. Further study is needed to test the possibility that specific interventions may carry specific advantage in other settings or with other patient groups. The nature and quality of institutional support for such research itself needs strengthening. In this case, the institutions' intention to assist was robust, but real understanding and/or sustained ability to facilitate it is lacking. This problem is hardly unique to this setting.

Developing and comparing methods for measuring the content of care in mental health services

BACKGROUND

Measurement of what happens in mental health services is needed to describe services, identify variation in care provision and understand service outcomes. However, there is no consensus about appropriate methods or measures for content of care. Previous research has primarily used a single information source and prioritised staff over patient perspectives on content of care. This study aims to enhance understanding of how to measure content of care by developing and evaluating four instruments, each using a different measurement method.

METHODS

Development is described by four instruments-CaSPAR, CaRICE, CCCQ-S and CCCQ-P-which use researcher observation, staff-report and patient-report to measure the intensity and nature of care at services. Inter-rater reliability of CaRICE and CCCQ-S was investigated. Concordance between staff and patient perspectives was explored through assessing inter-rater agreement of CCCQ-S and CCCQ-P questionnaires. The convergence of data from the measures collected in an inpatient multi-site study was investigated.

RESULTS

CaRICE demonstrated good inter-rater reliability (κ = 0.71). CCCQ-S inter-rater reliability was poor. Concordance between staff and patient reports was low: there was a trend for patients to report less care received than staff reported had been provided. Results from CaSPAR, CaRICE and CCCQ-P exhibited divergence, indicating possible differences in patient, staff and researcher perspectives.

DISCUSSION

Information about content of care should be sought as close as possible to the point of delivery. There may be differing, valid perspectives about care provided by services. Further development of methods to measure content of care is required. Meanwhile, a multi-methods approach should be adopted, which allows inclusion of different perspectives (specifically including the patient's perspective) and triangulation of results from different measurement methods. CaSPAR, CaRICE and CCCQ-P can provide multi-perspective content of care measurement in inpatient services.

The Measurement of the Quality of Care in Psychiatric Rehabilitation Settings: Development of the Model Standards Questionnaires

The need to monitor the standards of care provided in settings for the long term psychiatrically disabled has become increasingly recognized. A critical review of the literature indicated that no comprehensive assessment procedure existed for settings providing some form of rehabilitation. However, five important aspects of care in each setting were identified: (i) Treatment Practices, (ii) Unit Management Practices, (iii) Community Contact Practices, (iv) The Physical Environment and (v) Staffing Resources.

A series of questionnaires was devised—The Model Standards Questionnaires—to assess each of these aspects of care. The questionnaires can be used to provide a profile of particular settings quality of rehabilitation and as a means of identifying how the quality of that rehabilitation might be improved.

Assessing the content of mental health services: a review of measures

BACKGROUND

Measurement of service content is necessary to understand what services actually provide and explain variation in service outcomes. There is no consensus about how to measure content of care in mental health services.

METHOD

Content of care measures for use in mental health services were identified through a search of electronic databases, hand searching of references from selected studies and consultation with experts in the field. Measures are presented in an organising methodological framework. Studies which introduced or cited the measures were read and investigations of empirical associations between content of care and outcomes were identified.

RESULTS

Twenty five measures of content of care were identified, which used three different data collection methods and five information sources. Seven of these measures have been used to identify links between content of care and outcomes, most commonly in Assertive Community Treatment settings.

DISCUSSION

Measures have been developed which can provide information about service content. However, there is a need for measures to demonstrate more clearly a theoretical or empirical basis, robust psychometric properties and feasibility in a range of service settings. Further comparison of the feasibility and reliability of different measurement methods is needed. Contradictory findings of associations between service content and outcomes may reflect measures' uncertain reliability, or that crucial process variables are not being measured.

CONCLUSION

Measures providing a greater depth of information about the nature of interventions are needed. In the absence of a gold standard content of care measure, a multi-methods approach should be adopted.

Day centres for severe mental illness

BACKGROUND

The number of people with severe mental illness who receive treatment whilst living at home has increased greatly over the last 30 years. Day centres and day hospitals frequently supplement this treatment.

OBJECTIVES

To determine the effects of non-medical day centre care for people with severe mental illness.

SEARCH STRATEGY

We updated our search in September 2005. All databases and searches are detailed in the body of the text.

SELECTION CRITERIA

We would have included all randomised controlled trials where seriously mentally ill people were allocated to non-medical day centre care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, it had been hoped to estimate the fixed effects Relative Risk (OR) with 95% confidence intervals (CI) and the number needed to treat statistic (NNT). Analysis was to have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD) and scale data presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

Electronic searches identified over 300 citations but none were relevant to this review. We found no trials of non-medical day centres.

AUTHORS' CONCLUSIONS

We feel that the inclusion of any studies less rigorous than randomised trials would result in misleading findings and that it is not unreasonable to expect well designed, conducted and reported randomised controlled trials of day centre care. More precise nomenclature would greatly help identify relevant work. At present non-randomised comparative studies give conflicting messages about the roles provided by day centres and the clinical and social needs they are able to meet. It is therefore probably best that people with serious mental illness and their carers, if given the choice, take a pragmatic decision on which type of unit best meets their needs. There is a clear need for randomised controlled trials of day centre care compared to other forms of day care, and when resources are limited, day centre care within the context of a pragmatic randomised trial may be the only way of ensuring equity of provision.

Day centres for severe mental illness

BACKGROUND

The number of people with severe mental illness who receive treatment whilst living at home has increased greatly over the last 30 years. Day centres and day hospitals frequently supplement this treatment.

OBJECTIVES

To determine the effects of non-medical day centre care for people with severe mental illness.

SEARCH STRATEGY

The Allied and Complementary Medicine Database (1985-1999), The British Nursing Index (1994-1998), The Cochrane Library (Issue 2, 1999), The Cochrane Schizophrenia Group's Register (May 1999), EMBASE (1980-1999), MEDLINE (1966-1999), PsycLIT (1887-1999), The Royal College of Nurses Database (1985-1996), and Sociological Abstracts (1963-1999) were searched. References of all identified studies were also inspected for more studies.

SELECTION CRITERIA

All randomised controlled trials where seriously mentally ill people were allocated to non-medical day centre care.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data, it had been hoped to estimate the Peto odds ratios (OR) with 95% confidence intervals (CI) and the number needed to treat statistic (NNT). Analysis was to have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD) and scale data presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

Despite extensive searching, no trials were found of non-medical day centres. The electronic search identified over 300 citations but none was relevant to this review.

REVIEWER'S CONCLUSIONS

The reviewers feel that the inclusion of any studies less rigorous than randomised trials would result in misleading findings and that it is not unreasonable to expect well designed, conducted and reported randomised controlled trials of day centre care. More precise nomenclature would greatly help identify relevant work. At present non-randomised comparative studies give conflicting messages about the roles provided by day centres and the clinical and social needs they are able to meet. It is therefore probably best that people with serious mental illness and their carers, if given the choice, take a pragmatic decision on which type of unit best meets their needs. There is a clear need for randomised controlled trials of day centre care compared to other forms of day care, such as day hospitals.

Residential care in hospital and in the community--quality of care and quality of life

BACKGROUND

The reduction of beds in long-stay hospitals has led to concerns over the quality of care offered to the remaining residents as well as that provided in the community. This study seeks to compare the quality of care and quality of life (reported satisfaction) from residents in both types of setting.

METHOD

A cross-sectional comparison was made of community residential homes and hospital wards drawn randomly from lists provided by local authorities in the outer London area. Samples were drawn from all the main provider types (local authority, housing association, private and joint NHS/voluntary sector). Measures were taken of the quality of the physical environment, staff and resident characteristics, external management arrangements and internal management regimes, resident satisfaction and staff stress. Direct observations were also made of the amount and quality of staff-resident interactions.

RESULTS

In general, the most disabled residents were found to be still living in hospital in the Worst conditions and receiving the poorest quality of care. Although there were some problems with missing data, hospital residents also seemed most dissatisfied with their living situation. There were few differences between community providers regarding either the quality of care provided or the levels of reported satisfaction. Quality of care in the community homes seemed to be much more determined by the personality and orientation of project leaders.

CONCLUSIONS

Purchasers and providers still need to give attention to the problems of selectively discharging the most able residents to the community, leaving the most disabled being looked after in progressively deteriorating conditions. All residential providers need to review their internal management practices and try to ensure that residents are offered, as far as possible, the opportunity to make basic choices about where and how they will live. Staff training and quality assurance practices need to be reviewed in order to improve the direct quality of care offered to the most disabled individuals.

Reasons for non-attendance at a day hospital for people with enduring mental illness: the clients' perspective

This paper describes a research project which aimed to discover the reasons clients give for failing to attend a mental health day hospital. There was concern that this service provision, for people with enduring mental illness, had a high level of non-attendance and therefore might not be meeting the needs of the people for whom it is targeted. Over a period of 6 months 36 people failed to attend, despite assessment and apparent agreement to attend. Of the 36, 14 agreed to talk about their reasons for not attending. An open interview format was used which enabled the clients to talk in depth about their experiences, which they felt led to the decision to stop attending. Content analysis of the interview data resulted in the identification of common themes. Main findings suggest a lack of partnership in decisions on choice of therapy, particularly the emphasis on groupwork, which 86% found unhelpful. Other main factors for non-attendance were a lack of an individual approach to care, not being listened to, and a lack of warmth from the staff. Recommendations for future practice are given, with particular attention to the need to develop a partnership with clients aimed at meeting individual needs.

Whose quality of care is it anyway? Methodological issues in evaluating residential care for the mentally ill

The paper reports on issues of methodology regarding the evaluation of residential care for mentally ill people. A literature review examines the development of research approaches to studying residential care practices, from qualitative descriptive studies to quantitative comparative studies. The difficulty of definition and measurement in high-quality residential care is discussed. Findings are presented from an ethnographic study of care structure and process, and the experience of staff and clients, conducted in two residential care settings. Anomalies are reported in the use of quantitative and qualitative research methods. There is a discussion of methodological issues that arise from anomalous findings.

The Mental Impairment and Evaluation Treatment Service: staff attitudes and staff-client interactions

This study describes and evaluates a new short-term residential service for adults with mild learning difficulties and challenging behaviour, the Mental Impairment Evaluation and Treatment Service. The study examines staff attitudes towards management practices, towards the potential achievement of individuals with learning difficulties, the staff's perceived involvement in decision making, and also the nature of their interaction with the clients, in two different settings on the Unit. The Unit's management practices were found to be client-orientated in nature and staff were more in agreement with client-orientated than institution-orientated management practices. Staff were generally optimistic about clients' potential and felt involved in decision making. Correlations between certain staff characteristics, attitudes and interactions are discussed. The study extends the range of services that have been evaluated in this way, and provides a description of the service in its early stages, which will provide an important comparison point for it when it is more permanently established.

Staff-patient relationships in the care of the long-term adult mentally ill. A content analysis of Expressed Emotion interviews

Analysis of the content of 61 interviews with keyworkers supporting chronically disabled patients in long-term care settings revealed a range of EE ratings and associated characteristics. Low-EE interviews were prevalent (n = 46), a finding not unlikely given the experience and training of the staff group sampled. High-EE (n = 15) relationships were characterised by less tolerance, inappropriate expectations of patient progress and frustration in the key worker. Criticism in both high- and low-EE interviews was most frequently focused on socially embarrassing or difficult behaviour and, to a slightly lesser extent, the clinical poverty syndrome. It was rarely directed at positive symptomatology. High levels of criticism were significantly related to regarding the patient's difficulties as within their control and having negative rather than positive expectations of their ability to manage on their own. The factors identified by the EE interview that influence the nature of the staff-patient relationship are discussed, and the clinical implications of the findings briefly considered.

Expressed Emotion in community care staff. A comparison of patient outcome in a nine month follow-up of two hostels

Expressed Emotion was measured in the staff of two similar hostels for the long term mentally ill in an Inner London Borough (Hostel A and Hostel B). Patients in the two hostels showed similar levels of disturbance as measured by the PSE and symptom and behaviour profile scores. Staff from Hostel B displayed higher levels of EE, and were more critical, and these attitudes generalised easily into hostility and rejection. Those from Hostel A showed lower EE with warmth and positive attitudes towards clients. At 9 month follow up, Hostel A and B had similar levels of relapse requiring hospital admission. However Hostel B had a 64% discharge rate compared with 12.5% for Hostel A. These results are discussed with reference to the literature.

A comparison of practices, attitudes and interactions in two established units for people with a psychiatric disability

This study evaluates and compares aspects of residential care in a community hostel setting and a hospital setting for people with a psychiatric disability. The clients were assessed to establish their level of general functioning, the comparison indicating there was no significant difference between the two groups on the measure used. A previously published protocol was used as a method of comparing the units. The findings indicated that the hospital unit was more individually orientated both in practices and staff attitudes, and had staff who were more optimistic about clients' potential accomplishments. No differences were found between perceived involvement of staff in decision making, or staff resident interactions. These findings have implications for the 'Care in the Community' movement, as they indicate that the nature of a service is as important as its location. They suggest that the relocation of services to the community in itself will not automatically overcome some of the difficulties associated with institutional care.

Psychiatric day care: the users' perspective

The literature on consumer opinion about psychiatric day care is reviewed and a study of the views of day care attenders living in an inner city catchment area who are in prolonged contact with psychiatric services is presented. Attenders were broadly satisfied with their care. Analysis of their verbatim comments suggested that attenders perceived the value of attendance at a day unit in social rather than therapeutic terms. The implications of this finding are discussed.

Developments in psychiatric day care

Although day care for the mentally ill has been used for almost forty years the potential of the service has not been fully utilised and the movement lacks any sense of overall direction. Day hospitals, the major provider of day care places, have expanded because of practical and financial pressures rather than by their own merit. Meanwhile, day centres have failed to make any significant impact on the psychiatric system, due to a lack of funding to local authorities and their consequent lack of commitment. The result has been a ratherad hocdevelopment of services and a failure to rationalise their activities.

Rehabilitation in psychiatric conditions: 1--Community and residential care

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A new unit for long-stay psychiatric patients: organization, attitudes and quality of care

The present study describes and evaluates aspects of care in a new residential unit for chronic patients. The findings suggest that the unit is relatively resident-orientated in its management practices and that the staff are similarly orientated in their attitudes. Staff also hold generally optimistic attitudes to residents' potential accomplishments and consider themselves highly involved in decision-making. They also show high levels of positive interactions with the residents. Various aspects of staff attitudes and behaviour are positively correlated with seniority or length of time on the unit. The results are discussed in terms of the unit's organizational structure and its possible impact on residents' functioning.