An evaluation of the implementation of case management in the community psychiatric nursing service

An unexpected visitor and a sword play: a randomized controlled trial of collective narrative therapy groups for primary carers of people with schizophrenia

BACKGROUND

Most family carer support programs focus on supporting carers with caregiving-related knowledge and skills to help their family members who suffer from schizophrenia in their recovery process while carers' inner resources and preferred identities are less emphasized in the existing studies.

AIMS

The present study uses collective narrative therapy groups (CNTG) to promote the inner strengths and agency of family carers and help them to explore their preferred identities while caring for family members with schizophrenia.

METHOD

To ensure an evidence-based intervention, 89 Chinese family carers of people with schizophrenia took part in this three-wave longitudinal program evaluation study using a randomized controlled trial design.

RESULTS

Compared with the control group, family carers in CNTG reported better family relationships, a lesser caregiving burden, and more perceived inner resources. Repeated one-way ANOVA revealed that CNTG improved family relationships, the caregiving burden, the level of hope and inner resources in the posttest, and a statistically significantly better mental health condition in the follow-up.

CONCLUSION

This study shows that collective narrative psychotherapy is effective in supporting family carers of people with schizophrenia in Hong Kong. Based on the research findings, we discuss the strengths of the program and its implications for practitioners.

Psychoeducation Program for Chinese Family Carers of Members With Schizophrenia

The purpose of this study was to evaluate the effectiveness of a psychoeducation program for Chinese family carers of members with schizophrenia in Hong Kong. The participants consisted of 64 carers of clients with schizophrenia who were recruited from a local mental hospital and randomly assigned to the experimental and control arm (32 each). The experimental group received a psychoeducation program developed and implemented by mental health nurses based on Atkinson and Coia’s framework. The control group received routine care. The outcome measures were family burden, self-efficacy, and perception of social support. The findings showed that the experimental group had more improvement on their perception of burden of care (t = 5.25, p< .01), self-efficacy (t = -7.16, p< .01), and social support (t= -5.61, p < .01). This study supports psychoeducation as an effective nursing intervention for Chinese family carers.

Comparison of the Quality of Life, Perceived Stigma and Medication Adherence of Chinese with Schizophrenia: A Follow-Up Study

OBJECTIVES

The community-based mental health services were encouraged to improve the quality of life for individuals with chronic mental disorders in Mainland China. This study aims to explore how the quality of life, perceived stigma, and medication adherence differ among a Chinese population with schizophrenia prior to and one-month following discharge.

METHOD

One hundred and twenty-eight Chinese people with schizophrenia completed the self-report scales: the Schizophrenia Quality of Life Scale (SQLS), the Link' Stigma Scale, and the Morisky Medication Adherence Scale (MMAS-8) prior to discharge and at one month after discharge. Data were analyzed using descriptive statistics and a paired sample t-test.

RESULTS

The findings of SQLS demonstrate deterioration on psychosocial and motivation/energy domain (P<0.001) accompanied by improvement of symptom/side effect (P<0.05) after discharge. The scores of perceived stigma and actual stigma coping orientations (P<0.001) after discharge were found to be significantly higher than before discharge. Medication adherence was significantly reduced after discharge than before discharge (P<0.001).

CONCLUSION

The results of this study provide implications for clinical practices, such as provision of psychosocial and educational rehabilitation programs for individuals who are in a stable mental status and plan to discharge; and to provide effective family education in order to improve family coping strategies and caring capabilities when patients return to the community. The findings provide important policy implications as well to facilitate individuals with schizophrenia to reintegrate into the community and benefit from a favorable QOL.

Integrating Evidence-Based Community-Care Services to Improve Schizophrenia Outcomes: A Preliminary Trial

This aim of this preliminary experimental study was to integrate effective evidence-based community-care services that are subjected to heavy caseloads, and to then examine the effects on individuals with schizophrenia. Using a cluster sampling method, four homecare nurses were randomly assigned to either the experimental group or the comparison group. The nurses in the experimental group applied the following six identified effective elements: (1) established an alliance with their patients; (2) assessed patient-care needs; (3) considered both medical and social-care practices; (4) addressed patients' self-management of medication and their daily tasks; (5) provided crisis intervention; and (6) coordinated resources. The patients comprised 85 individuals with schizophrenia. In the experimental group, psychiatric homecare nurses were randomly assigned to implement integrated, evidence-based community-care services during a six-month follow-up period. Patients in the comparison group continued to receive their customary community care. In the experimental group, patient satisfaction scores, medication attitudes, and general functioning levels were significantly higher than in the comparison group. These preliminary findings indicate a potentially effective model for community care in areas where intensive case management cannot be provided.

Systematic synthesis of barriers and facilitators to service user-led care planning

BACKGROUND

Service user (patient) involvement in care planning is a principle enshrined by mental health policy yet often attracts criticism from patients and carers in practice.

AIMS

To examine how user-involved care planning is operationalised within mental health services and to establish where, how and why challenges to service user involvement occur.

METHOD

Systematic evidence synthesis.

RESULTS

Synthesis of data from 117 studies suggests that service user involvement fails because the patients' frame of reference diverges from that of providers. Service users and carers attributed highest value to the relational aspects of care planning. Health professionals inconsistently acknowledged the quality of the care planning process, tending instead to define service user involvement in terms of quantifiable service-led outcomes.

CONCLUSIONS

Service user-involved care planning is typically operationalised as a series of practice-based activities compliant with auditor standards. Meaningful involvement demands new patient-centred definitions of care planning quality. New organisational initiatives should validate time spent with service users and display more tangible and flexible commitments to meeting their needs.

Road to better health and integration: a Delphi study on health service models for Hong Kong migrants

Introduction

In Hong Kong, migrants arriving from Mainland China often have multiple roles and responsibilities while adapting to new lives in their host destination. This paper explored the factors that contribute to the inequity in health services utilisation experienced by these migrants; and, identified the elements that could constitute an effective health delivery model to address the service gap.

Methods

Site visits and a focus group discussion (n = 13) were held with both public and private health providers before a number of innovative health delivery models were formulated. They were then circulated among the panel in two further rounds of Delphi survey (n = 11) from March-April 2012 to systematically collect opinions and select the most endorsed health service models to serve this target population.

Results

Focus group members perceived that most migrants were unaware of, or even ignored, their own physical and mental health needs, and had low utilisation of healthcare services, because of their pre-occupation with daily chores and hardship as well as differing health values, practices and expectations. They further identified that the structural issues such as the healthcare setting or the operation of current service provisions had failed to meet migrants’ health needs. Consequently, four new service models that incorporated professional advice and empowerment, which were identified as the two most important elements, were put forward. Thus, the model of having a nurse with social work training, supported by volunteer groups, was selected as the best option to familiarise and empower patients within the labyrinth of local healthcare services.

Conclusion

Implementation of a social empowerment model by way of targeted support and specific health information is recommended. Further evaluation of this model is needed to understand its effectiveness for improving health literacy and health status in this disadvantaged group in the long term.

Impact of personalized in-home nursing care plans on dependence in ADLs/IADLs and on family burden among adults diagnosed with schizophrenia: a randomized controlled study

PURPOSE

The study aims to assess the impact of personalized in-home nursing care plans on the degree of dependence among adult patients with schizophrenia, and on family burden.

DESIGN AND METHODS

This is a randomized controlled study with 94 participants: The experimental group received a personalized in-home nursing care plan. The comparison group got a standard care at its mental health center.

FINDINGS

The pretest-posttest multivariate analysis of covariance revealed statistically significant group differences (p = .003). The help received the positive activity and the degree of independence in the experimental group improved mainly due to intervention.

PRACTICE IMPLICATIONS

A personalized in-home nursing care plan improves the degree of independence of people diagnosed with schizophrenia living in the community and reduces the burden perceived by the family.

Recovering from hallucinations: a qualitative study of coping with voices hearing of people with schizophrenia in Hong Kong

Auditory hallucination is a positive symptom of schizophrenia and has significant impacts on the lives of individuals. People with auditory hallucination require considerable assistance from mental health professionals. Apart from medications, they may apply different lay methods to cope with their voice hearing. Results from qualitative interviews showed that people with schizophrenia in the Chinese sociocultural context of Hong Kong were coping with auditory hallucination in different ways, including (a) changing social contacts, (b) manipulating the voices, and (c) changing perception and meaning towards the voices. Implications for recovery from psychiatric illness of individuals with auditory hallucinations are discussed.

Effects of community-based case management by visiting nurses for low-income patients with hypertension in South Korea

AIM

To assess the effects of a visiting nurse-driven community-based case management program for low-income adults with hypertension.

METHODS

This single group pretest-post-test study included 22 newly registered low-income adult patients with hypertension in a public health center in Seoul. Visiting nurses delivered a case management program for 2-8 months. Pretest and post-test measurements of blood pressure (BP), knowledge level, and self-management level in terms of diet, lifestyle, physical activity, and medication were obtained.

RESULTS

The visiting nurse-driven case management was effective in reducing the BP level and improving the knowledge and self-management level of the low-income adults with hypertension in the community.

CONCLUSION

This study serves as a baseline for visiting nurse-driven case management for low-income patients with hypertension. Its findings suggest that visiting nurse-driven case management targeting the self management of BP can foster improved BP control for newly diagnosed hypertensive patients in low-income populations.

Global perspective of burden of family caregivers for persons with schizophrenia

Schizophrenia is a severe form of mental illness that affects about 7 per 1,000 of the adult population. It is estimated that globally about 29 million people have schizophrenia. With the advent of deinstitutionalization, most persons with schizophrenia are now being cared for in the community by their families. Living with a relative with severe mental illness is stressful. Burden of care is a global issue affecting family caregivers in both developed and developing countries. This article aims to examine the burden of family caregivers for persons with schizophrenia and the socioeconomic factors that influence the caregivers' perception of burden. There is a general agreement that family interventions are beneficial to family caregivers. Therefore, this article examines two of the most commonly investigated interventions: psychoeducation and support groups, for family caregivers of persons with schizophrenia.

Evaluation of a psychoeducation program for Chinese clients with schizophrenia and their family caregivers

OBJECTIVES

To evaluate the effectiveness of a psychoeducation program for Chinese clients with schizophrenia and their family caregivers.

METHODS

A randomized controlled trial was conducted. Seventy-three clients with a diagnosis of schizophrenia and their caregivers (n=73) were recruited and randomized into a study (n=36) and control group (n=37). Ten psychoeducation sessions were provided to the study group. The outcomes were measured at the baseline, immediately after (post-1), six months (post-2), and 12 months after the intervention (post-3).

RESULTS

There were significant treatment effects across time for all client outcomes: adherence to medication (p<0.01), mental status (p<0.01), and insight into illness (p<0.01). However, no significant differences were found between groups at the post-3 measures for all client outcomes. For the caregivers, significant group differences were only detected in self-efficacy at the post-1 (p=0.007) and post-2 (p<0.001) measures, the level of satisfaction at the post-1 (p=0.033) and post-2 (p<0.021) measures, and the perception of family burden at the post-2 measures (p=0.043).

CONCLUSION

A psychoeducation intervention had positive effects on Chinese clients and their caregivers. However, these effects might not be sustained 12 months after the intervention.

PRACTICE IMPLICATIONS

To substantiate its effects, psychoeducation should be an ongoing intervention, with its outcomes constantly evaluated.

Assessment of dependency levels of older people in the community and measurement of nursing workload

AIM

This paper is a report of a study to explore the relationship between the dependency levels of older people who are part of the community nurse's caseload and the volume and nature of nursing input required.

BACKGROUND

International healthcare policy has consistently emphasized the reorientation of health services from hospital to community care. It is necessary to determine ways to use nursing resources appropriately to meet service needs of an increasing older population.

METHOD

This quantitative study was conducted in one region of Ireland, which included a city and sparsely populated rural areas. Over a 4-week period in 2004, a volunteer sample of 44 nurses assessed all older people (1482) on their community caseload using the Community Client Need Classification System. In addition, participants recorded the amount of care time spent with each individual client by all members of the community nursing team.

FINDINGS

The vast majority of clients were seen in their own homes (85%, n = 1259). On the 5-point Community Client Need Classification System, the majority (39%, n = 571) were assessed at level 2 (low level of need) and 4% (n = 61) at level 5 (high level of need). As client need level increased, the consumption of community nursing time also increased.

CONCLUSION

The tool was successful in discriminating between care needs levels of older people and may be useful in predicting the type and amount of human resources required by individuals who need community nursing services. Lack of information on demographic variables may limit the transferability of these findings.

Evaluations of community mental health care in low- and middle-income countries: A 10-year review of the literature

Community-based models of providing mental health services are widely considered effective ways of serving individuals diagnosed with mental illness, but more comprehensive literature on these models in low- and middle-income countries is needed. This study is a systematic review of the effects of community-based models on health outcomes of adults with depression, schizophrenia, panic disorder, or bipolar disorders in middle- and low-income countries. PubMed, PsycINFO, and Cochrane Reviews were searched, returning 500 articles. The seventeen interventions included in this review in 14 countries show us that community-based mental health services can provide improvements in mental health outcomes, and the limited cost analyses suggest cost savings associated with community models of care. These findings are in line with much of the research on higher income countries. In addition, the studies also point to the gaps in the literature on costs, rural areas, bipolar disorders, and panic disorders, and note the need for further reviews of interventions targeting additional diseases, children, and adolescents as well as studies published in languages other than English. This review of the literature serves as a stepping stone for further research in community-based mental health services in low- and middle-income countries. The works reviewed here provide a base of knowledge that will assist us in taking the important next steps in program implementation and evaluation.

Clinical correlates of clozapine prescription for schizophrenia in China

AIMS

Few studies have investigated the prescription patterns of clozapine in outpatients with schizophrenia in China. It is an important issue due to clozapine's high efficacy and potentially fatal side effect profile. This study examined the use of clozapine and its correlates in China.

METHODS

Three hundred ninety-eight clinically stable outpatients with schizophrenia were randomly selected and interviewed in Hong Kong (HK) and Beijing (BJ). Assessment instruments included the Structured Clinical Interview for DSM-IV, Brief Psychiatric Rating Scale, Simpson and Angus Scale of Extrapyramidal Symptoms, Barnes Akathisia Rating Scale and the Hong Kong and Mainland China World Health Organization Quality of Life Schedule-Brief version. Assessments were performed by the same investigator in both sites.

RESULTS

Clozapine was prescribed to 15.6% of (n = 62) patients. There was a wide inter-site variation between HK and BJ. Use of clozapine was associated with age, age at onset, extrapyramidal side effects (EPS), having health insurance, use of depot and typical antipsychotic and anticholinergic drugs and benzodiazepines as well as history of suicidal attempts. On multiple logistic regression analysis, the number of hospitalizations, site (HK vs. BJ), use of typical antipsychotics, polypharmacy and co-prescription with anticholinergics were significantly associated with the prescription of clozapine. No significant differences were found between the clozapine and non-clozapine groups with regard to any of the quality of life domains.

CONCLUSION

A combination of economical and clinical factors, health policies and the characteristics of the treatment settings plays important roles in determining clozapine use. Clozapine appears to have little significant influence on quality of life in clinical stable Chinese patients with schizophrenia.

Health-related quality of life of Chinese people with schizophrenia in Hong Kong and Taipei: A cross-sectional analysis

Health-related quality of life is an important outcome indicator of mental health. We assessed the perception of health-related quality of life of persons with schizophrenia in Hong Kong and Taipei. In-person survey interviews were conducted using the Chinese World Health Organization Quality of Life Scale--Brief Version. A convenience sample was recruited from psychiatric outpatient departments: 176 from Hong Kong and 80 from Taipei. We found that both groups were significantly less satisfied with their psychological and social relationship domains compared to other domains. Poor mental health predicted poor perception of health-related quality of life. Schizophrenia has an impact on many aspects of a person's functioning. A rehabilitation model that takes into account symptoms, financial situation, family support, and social functioning is required.

Nurse case management: negotiating care together within a developing relationship

TOPIC/PROBLEM: The purpose of this study was to explicate the process of nurse case management involving clients afflicted with chronic mental illness.

METHOD

Grounded theory was the method of choice. Interviews were conducted with nurses in inpatient, transitional, and community settings in four cities in southern Ontario, Canada.

FINDINGS

Negotiating care together within a developing relationship emerged as the basic social process. "Building a trusting relationship" was identified as the foundation of case management.

CONCLUSIONS

Salient differences were found between the three settings, yet the basic social process was consistent across settings. This underscores the therapeutic relationship as the basis for nurse psychiatric case management.

Quality of life of clients with schizophrenia

BACKGROUND

Because of the deinstitutionalization of mental health care in Hong Kong that has taken place since the 1980s, many people with mental health problems are being cared for in the community. The majority of clients have a diagnosis of schizophrenia, and many have a long duration of illness and multiple readmissions. There is concern about their quality of life.

AIM

To investigate quality of life and related factors in clients with a diagnosis of schizophrenia in Hong Kong.

DESIGN

A convenience sample was recruited from a psychiatric outpatient department. Structured face-to-face interviews were conducted using the Brief Psychiatric Rating Scale and the Hong Kong Chinese World Health Organization Quality of Life Scale-Brief Version.

RESULTS

A total of 172 people participated in the study. Most of them were single and unemployed. They were least satisfied with their psychological health, financial situation, life enjoyment and sexual activity. Women (n = 91) reported less satisfaction with quality of life than men (n = 86). Unemployed people (n = 100) were less satisfied with their quality of life than the employed (n = 76). Higher levels of mental health problems and higher numbers of previous hospitalizations were associated with negative perceptions of quality of life.

DISCUSSION

People with mental health problems had significantly less satisfaction with their quality of life than a sample from the general population in Hong Kong surveyed in a previous study. As well as experiencing distressing mental symptoms, they had many difficulties, such as financial problems, unemployment and lack of opportunities to participate in social activities, that resulted from stigma and discrimination. These had a great impact on their quality of life.

STUDY LIMITATIONS

Because of the small sample size and its convenience nature, the findings may not be generalizable to all clients in Hong Kong. A generic instrument was used to measure quality of life, and this may not have been sensitive to certain aspects of mental health clients' lives.

CONCLUSION

The findings suggest that there is a need to strengthen social and vocational rehabilitation for people with mental health problems in Hong Kong. A more holistic and intensive model of care is required to meet their complex needs. A larger and more diverse sample should be used in future research, and a quality of life measure specifically designed for people with mental health problems should be used.

Cognitive behavioural therapy for clients with schizophrenia: implications for mental health nursing practice

1. This paper discusses the application of cognitive behavioural therapy (CBT) in the treatment of clients with schizophrenia and the implications for mental health nursing practice. 2. The literature shows that CBT has positive effects for clients in improving mental state and reducing relapse rate. 3. Because of their direct client contact, mental health nurses are in the best position to assess, address and manage clients' psychotic symptoms and problems. 4. A nursing care plan is used to illustrate how the principles of CBT could be incorporated into nursing care. 5. Education and training are important to equip nurses with the necessary knowledge and skills to implement the therapy. 6. Nurses have to take into account cultural issues related to the use of CBT. 7. Culturally sensitive research needs to be conducted to assess the outcome of the therapy.