Perceptions on the standardization of psychiatric work: development of a care pathway

Preliminary Assessment of Pre-Electroconvulsive Therapy Evaluation Practices in European Countries: The Need for Guidelines

OBJECTIVES

Pre-electroconvulsive therapy (ECT) evaluation is an essential part of ECT preparation, a standard treatment in the psychiatric field. However, no routine pre-ECT evaluation has been published so far. This preliminary study aimed to explore different practices in pre-ECT evaluation across European countries.

METHODS

The data were collected as a snowball sample approach using an online survey from September 2019 to April 2020. The final analysis included data from 18 clinics placed in 16 European countries.

RESULTS

Regulations on the pre-ECT evaluation were found in 9 countries. All clinics reported doing complete blood count, serum electrolytes, and renal function analysis as a part of regular laboratory testing, alongside with a cardiovascular assessment. Ten clinics reported using psychiatric scales. Six clinics reported doing a cognitive assessment, of which all had regulations on the pre-ECT evaluation. Not one evaluation had the same sets of procedures and diagnostics.

CONCLUSIONS

The differences in assessment approaches mirror high variability of the pre-ECT evaluation practice across Europe. Cognitive assessment and objectification of psychiatric symptoms should be a regular part of the pre-ECT evaluation because of the monitoring of the most common adverse effect and observing the clinical response to ECT. Standardization of the pre-ECT evaluation and ECT in general would remove criticisms and opposition to the treatment, make it based on the best of our knowledge, and provide a method respectful of patients' best interests and rights.

Trust in pathways? Professionals' sensemaking of care pathways in the Norwegian mental health services system

BACKGROUND

In January 2019, care pathways within specialist mental health and substance abuse treatment services were officially launched in Norway. The care pathway introduced timeframes for assessment and treatment, allowing a maximum of 6 weeks to finish assessment and provide the patient with a diagnosis, in addition to allowing a maximum of 6 weeks from diagnosis to the first evaluation. The different action points required coding. The system was based on goals to improve services by focusing on user participation, coordinated patient flow, avoidance of unnecessary waiting time, improvement of equal access to services regardless of geographic location, and increased emphasis on physical health and lifestyle. The purpose of our study was to examine how mental health professionals made sense of care pathways and furthermore, how issues of trust affected the process of implementation.

METHODS

Our multiple case study included four outpatient clinics for adults in four community mental health centres (CMHCs) in different parts of Norway. Qualitative data were collected through in-depth individual and focus group interviews and analysed using systematic text condensation. The informants were treatment personnel and leaders in four different outpatient clinics for adults.

RESULTS

The results indicated four distinct themes or reactions to the care pathway and its implementation: 1) lack of clarity regarding the overall goals and content of the care pathway; 2) the increased burden of coding, registration and administrative work, which professionals experienced as a stressor; 3) an IT and medical record system that did not correspond to the coding of the care pathway; and 4) an unrealistic distinction between assessment and treatment. These themes/reactions increased the health professionals' distrust towards the care pathway, and a process of sensemaking encouraged them to reduce the importance of the care pathway system and its implementation.

CONCLUSION

Theories of trust help in understanding how mental health professionals interpret care pathway implementation. Distrust and resistance towards the care pathways overshadow some of the overall quality goals of the care pathway, a view that was indeed shared by mental health professionals.

Grey Matters: 2006 and all that

The article is intended to put the current NHS dental contract in england into context and identify areas where there has been confusion about interpretation of certain clauses. the article describes these as grey areas and provides a rationale for logically interpreting these issues, such as urgent treatment, mixing NHS and private treatment and defining what a course of treatment is.<br/> These are the views of the authors based on significant personal experience of the contract, both as practitioners and as dento-legal advisers.

General practitioner experience and perception of Child and Adolescent Mental Health Services (CAMHS) care pathways: a multimethod research study

OBJECTIVES

This is a pilot study with the objective of investigating general practitioner (GP) perceptions and experiences in the referral of mentally ill and behaviourally disturbed children and adolescents.

DESIGN

Quantitative analyses on patient databases were used to ascertain the source of referrals into Child and Adolescent Mental Health Services (CAMHS) and identify the relative contribution from GP practices. Qualitative semistructured interviews were then used to explore challenges faced by GPs in referring to CAMHS.

SETTING

GPs were chosen from the five localities that deliver CAMHS within the local Trust (Peterborough City, Fenland, Huntingdon, Cambridge City and South Cambridgeshire).

PARTICIPANTS

For the quantitative portion, data involving 19 466 separate referrals were used. Seven GPs took part in the qualitative interviews.

RESULTS

The likelihood of a referral from GPs being rejected by CAMHS was over three times higher compared to all other referral sources combined within the Cambridge and Peterborough NHS Foundation Trust. Interviews showed that detecting the signs and symptoms of mental illness in young people is a challenge for GPs. Communication with referral agencies varies and depends on individual relationships. GPs determine whether to refer on a mixture of the presenting conditions and their perceived likelihood of acceptance by CAMHS; the criteria for the latter were poorly understood by the interviewed GPs.

CONCLUSIONS

There are longstanding structural weaknesses in the services for children and young people in general, reflected in poor multiagency cooperation at the primary care level. GP-friendly guidelines and standards are required that will aid in decision-making and help with understanding the referrals process. We look to managers of both commissioning and providing organisations, as well as future research, to drive forward the development of tools, protocols, and health service structures to help aid the recognition and treatment of mental illness in young people.

Initiating end-of-life care pathways: a discussion paper

AIMS

To discuss the intricacies of the decision-making process about initiating end-of-life care pathways.

BACKGROUND

Internationally, enhancing the quality of end-of-life care has become a central concern in governments' health policies. Despite limited empirical evaluation, end-of- life care pathways have been championed and widely adopted as complex interventions to enhance end-of-life care worldwide.

DATA SOURCES

A literature search of established electronic databases was conducted for published articles in English addressing decision-making and end-of-life care pathways between 1997-2010. Manual searches of relevant journals and internet sites were also undertaken.

DISCUSSION

The initiation of an end-of-life care pathway marks the transition to the terminal phase of care. Although guidance for commencing these pathways exists, this may not overcome the complexities of the decision-making process, which must be viewed in context, namely: marking the transition to terminal care, dealing with ambiguity, reaching professional consensus and engaging patients and families. Implications for nursing. Nurses in all care settings have an important role in easing the transition to end-of- life care. Accordingly, nurses need not only an appreciation of end-of-life care pathways, but the complexities surrounding the decision to commence a pathway and their role within.

CONCLUSION

The initiation of an end-of-life care pathway is contingent on the outcome of a complex decision-making process which is rarely explored and poorly understood.

End-of-life care pathways as tools to promote and support a good death: a critical commentary

This paper calls into question whether and how end-of-life care pathways facilitate the accomplishment of a 'good death'. Achieving a 'good death' is a prominent social and political priority and an ideal which underpins the philosophy of hospice and palliative care. End-of-life care pathways have been devised to enhance the care of imminently dying patients and their families across care settings and thereby facilitate the accomplishment of a 'good death'. These pathways have been enthusiastically adopted and are now recommended by governments in the UK as 'best practice' templates for end-of-life care. However, the literature reveals that the 'good death' is a nebulous, fluid concept. Moreover, concerns have been articulated regarding the efficacy of care pathways in terms of their impact on patient care and close analysis of two prominent end-of-life pathways reveals how biomedical aspects of care are privileged. Nonetheless drawing on a diverse range of evidence the literature indicates that end-of-life care pathways may facilitate a certain type of 'good death' and one which is associated with the dying process and framed within biomedicine.

Facilitators and barriers to implementing clinical care pathways

BACKGROUND

The promotion of care pathways in the recent Governmental health policy reports of Lord Darzi is likely to increase efforts to promote the use of care pathways in the NHS. Evidence on the process of pathway implementation, however, is sparse and variations in how organisations go about the implementation process are likely to be large. This paper summarises what is known about factors which help or hinder clinicians in adopting and putting care pathways into practice, and which consequently promote or hinder the implementation of scientific evidence in clinical practice.

DISCUSSION

Care pathways can provide patients with clear expectations of their care, provide a means of measuring patient's progress, promote teamwork on a multi-disciplinary team, facilitate the use of guidelines, and may act as a basis for a payment system. In order to achieve adequate implementation, however, facilitators and barriers must be considered, planned for, and incorporated directly into the pathway with full engagement among clinical and management staff. Barriers and/or facilitators may be present at each stage of development, implementation and evaluation; and, barriers at any stage can impede successful implementation. Important considerations to be made are ensuring the inclusion of all types of staff, plans for evaluating and incorporating continuous improvements, allowing for organisational adaptations and promoting the use of multifaceted interventions.

SUMMARY

Although there is a dearth of information regarding the successful implementation of care pathways, evidence is available which may be applied when implementing a care pathway. Multifaceted interventions which incorporate all staff and facilitate organisational adaptations must be seriously considered and incorporated alongside care pathways in a continuous manner. In order to better understand the mechanism upon which care pathways are effective, however, more research specifically addressing conditions under which providers become engaged in using care pathways is needed.

Effect of introducing a care pathway to standardize treatment and nursing of schizophrenia

Care pathways can help to implement evidence-based clinical practice. The introduction of care pathways is difficult for psychiatric disorders. This study examined whether the organization and the effectiveness of care provided to schizophrenic patients can be improved by care pathways. Outcomes from 19 patients receiving treatment using evidence-based care pathways were compared with 17 patients receiving a traditional approach to care over a 3 months period. Results showed significant improvements in the quality of the care for the patients included in the care pathway group. The authors concluded the positive outcomes for patients treated with care pathways were related to the assistance provided to clinicians in identifying and implementing evidence-based standards.

A social constructionist analysis of talk in episodes of psychiatric student nurses conversations with clients in community clinics

AIM

This paper is a report of a study of the 'discursive doings' of psychiatric nursing students' practice as they are jointly constructed in conversations with clients in community psychiatric clinics.

BACKGROUND

This construction of psychiatric nursing as a therapeutic, holistic, person-centred, interactional process is central to the identity of psychiatric nursing as a discipline. However, recent studies are beginning to suggest a dissonance between the person-centred rhetoric and institutional practice.

METHODS

A discourse analysis was conducted in 2002-03 using the transcripts of seven conversations between nursing students and clients visiting psychiatric community clinics on a monthly basis. These were selected from a sample of 20 conversations based on their clarity and completeness. Texts were analysed using the notational systems of Silverman and Mishler and some of Fairclough's analytic text structure features.

FINDINGS

In all the transcripts, an agenda for surveillance was explicitly established in the students' opening sequences of each text. Almost all exchanges in the texts were organized around cycles of questions from students and responses from clients, which allowed students to control the conversations. Information delivery was also found to be at work within the texts, although it is not as prominent or as persistent as the question and answer structure. Students took up the responses of clients selectively as though working to a pre-set agenda.

CONCLUSION

These discursive activities manifest a symptom-like approach to nursing care and have the effect of disabling the development of client-authorized expressions of agency.

The implementation of the NICE guidelines for schizophrenia: barriers to the implementation of psychological interventions and recommendations for the future

PURPOSE

'Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care' was the first National Institute of Clinical Effectiveness (NICE) guidance to be produced in 2002. This guidance includes a recommendation in relation to cognitive behavioural therapy (CBT) and family interventions (FI) in schizophrenia. This review reviews this guidance and assesses the extent of their implementation in services and the barriers to this implementation.

METHODS

The review draws on data from empirical studies specifically focused on the NICE guidance for FI for schizophrenia, papers discussing implementation issues in relation to other psychological therapies in schizophrenia and empirical studies investigating the implementation of similar evidence-based guidelines in Australia and the USA.

RESULTS

Although there is relatively limited research investigating implementation of the NICE guidelines, the available evidence suggests that people with schizophrenia still have poor access to psychological interventions. Barriers to implementation involve factors associated with: mental health professionals, the needs of service recipients and of organizations.

CONCLUSIONS

In order to improve the implementation of the updated version of the schizophrenia guidance due to be published in 2009, it will therefore be necessary to target barriers at all of these levels. There are also problems associated with the way in which the NICE guidance, generally, and those for psychological interventions in schizophrenia in particular, are developed. It will be necessary to address these in order to facilitate successful implementation.

Feminist-informed participatory action research: a methodology of choice for examining critical nursing issues

Identifying a methodology to guide a study that aims to enhance service delivery can be challenging. Participatory action research offers a solution to this challenge as it both informs and is informed by critical social theory. In addition, using a feminist lens helps acquiesce this approach as a suitable methodology for changing practice. This methodology embraces empowerment self-determination and the facilitation of agreed change as central tenets that guide the research process. Encouraged by the work of Foucault, Friere, Habermas, and Maguire, this paper explicates the philosophical assumptions underpinning critical social theory and outlines how feminist influences are complimentary in exploring the processes and applications of nursing research that seeks to embrace change.

Supplementary prescribing: potential ways to reform hospital psychiatric care

The objective of this study was to explore perceptions held by nurses and psychiatrists towards the potential application of supplementary prescribing on acute psychiatric wards. Six focus groups were conducted with 19 nurses and seven psychiatrists who worked on three wards. Two major themes were identified: first, ways in which patients could receive care and treatment through supplementary prescribing and in new forms of partnership and second, ways by which nurses and psychiatrists could be organized to deliver their care through a supplementary prescribing framework. Nurses and psychiatrists were generally positive about the advent of prescribing and offered positive views as to how patient care could be improved and a general willingness for nurses to adapt and work differently. Findings from this exploratory study offer practical solutions to how supplementary prescribing could work on acute psychiatric wards.

Multidisciplinary team working: collaboration and conflict

The aim of this paper is to report on findings identifying some of the difficulties encountered by the multidisciplinary team in the development and implementation of a care pathway for patients diagnosed with schizophrenia. Policy direction has shifted towards greater team working and blurring of professional boundaries. Moreover, there is greater need to deliver care according to set standards and for patients to reach particular outcomes of care. Care pathways are relatively new for psychiatry and will potentially uncover tensions within the team. Data were collected by participant observation and semistructured interviews over a period of 12 months on an acute psychiatric unit. The care team developed the care pathway and the process of development and implementation was observed through action research. Cross-sectional indexing was used to analyse the data, and themes were developed using interview and observational data collection methods. Clinicians argued strongly for clear role boundaries but also defended their perceived control over health care from other professions. The findings indicate that designing a care pathway for people with schizophrenia may produce conflicting perceptions from the team. Conflict may arise through professions being unwilling to accept plurality over roles, which may hinder progress in meeting the needs of patients. The findings also counter the impression that care pathways can be implemented with little impact on the team.

Perceptions on individualized approaches to mental health care

Ways of working on acute psychiatric units have come under intense scrutiny in order for service users to receive modern care and treatment. This has led to various ways not only to improve the therapeutic milieu on psychiatric wards, but also to develop standardized approaches to care. This paper reports on a study on the development of a care pathway for people diagnosed with schizophrenia, with the aim of standardizing the care process. Action research was used to develop the care pathway and views were collected, and observations made from a range of mental health professionals. Not all respondents were in agreement with a care pathway and this led to clinicians defending the individualized nature of psychiatric care. Implementation of a care pathway may help not only to rekindle the therapeutic purpose of psychiatric care, but also to build in the individualized approach to carrying out hospital care. Limitations of the study have also been briefly reported.