In-patient psychiatric care: the patient's view

Saudi service users' perceptions and experiences of the quality of their mental health care provision in the Kingdom of Saudi Arabia (KSA): A qualitative inquiry

This paper presents, as part of a larger mixed-methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi-structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users' health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self-awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay's 'Cultural Originality' as well as contemporary examples of Goffman's mortification of the self.

Raiders of the Lost Art: A review of published evaluations of inpatient mental health care experiences emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia

Forming interpersonal therapeutic relationships with mental health Service Users remains a key aspect of the practice of Psychiatric/Mental Health nurses. Given the omnipresence of the concept within the relevant literature the reader could be forgiven for asking: why would Psychiatric/Mental Health nurses opine about something so basic, so ubiquitous and so central to the theory and practice of our discipline? While the authors could locate no substantive argument that refutes the role or value of such relationships, a sizable, growing and reasonably consistent body of work has emerged, which appears to indicate that this centrality and value is not necessarily reflected in many clinical practice settings. Accordingly, we draw on the published evaluations of mental health care emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia, compare these findings and highlight similarities or/and congruence and discuss a range of issues arising out of the findings. Alas, the findings seem to depict a mental health care inpatient experience that is often devoid of warm therapeutic relationships, respectful interactions, information or choice about treatment and any kind of formal/informal 'talk therapy'. Instead such care experiences are personified by: coercion, disinterest, inhumane practices, custodial and controlling practitioners and a gross over use of pharmacological 'treatments'.

What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use

Mental health nurses are in challenging positions. They have the opportunity to support people hospitalized for the treatment of mental illnesses on their recovery journeys, but are simultaneously required to manage a burgeoning administrative burden, maintain organizational 'order', and contain risk. While obliged by policy to engender an environment that promotes recovery, they receive little guidance about how this should be achieved. When feedback from people hospitalized in our service indicated the experience of care was variable, we undertook a pragmatic inquiry examining consumers' views about what makes an excellent mental health nurse. We interviewed 20 people with lived experience of hospitalization and analysed transcripts thematically. To ensure findings were relevant and useful, we consulted mental health nurses about nurses' needs, and incorporated this with the views of service users. The analysis demonstrated that personal qualities, professional skills, and environmental factors all influence the experience of mental health nursing. Our findings highlight a need for renewed attention to the basics of relationships and the importance for nurses of self-awareness and support. We urge nurses to make time to really get to know the people for whom they provide care, and to work to maintain passion for mental health nursing. It seems likely that attention to the simple things has the potential to improve levels of satisfaction among service users, decrease distress, and support the development of an environment in which can nurture recovery.

Patient satisfaction with psychiatric outpatient care in a university hospital setting

OBJECTIVES

To measure patient satisfaction with psychiatric outpatient care in a university hospital setting. We wished to ascertain whether there was an association between increased patient satisfaction and background factors such as demographic details, diagnosis and patient preference for outpatient treatment in a hospital or a community setting.

METHODS

We conducted a cross-sectional survey of individuals' satisfaction levels with their outpatient treatment. Outpatients were invited to complete the Client Satisfaction Questionnaire-8 (CSQ-8), a well validated self-report instrument, along with some additional questions on their attitudes to the service.

RESULTS

One hundred and sixty-two respondents had a mean total CSQ-8 score of 26.7 (s.d. = 4.6) indicating a moderate to high level of satisfaction with outpatient care. Ninety percent of patients were satisfied with their psychiatric outpatient care. There were no significant sociodemographic or clinical associations with satisfaction levels identified. Sixty one percent of patients were in favour of retaining outpatient care in the university hospital.

CONCLUSIONS

This study demonstrates high satisfaction levels with psychiatric outpatient care in a university hospital setting. The majority of patients expressed a preference for maintaining outpatient care in the general hospital setting, rather than transferring to a stand-alone mental health facility in a suburban setting.

Attitudes of mental health staff to protected therapeutic time in adult psychiatric wards

Therapeutic time is a relatively new, ward-based intervention whereby psychiatric nurses spend regular, uninterrupted periods of time with patients during which they do not attend to other matters. A questionnaire survey of nursing and medical staff was conducted to assess attitudes to the approach. The majority of staff viewed the approach as being important for promoting patient recovery, reducing risk, improving nurse-patient relationships and enhancing patient satisfaction with care received. Interference with medical activities, lack of staffing resources and variable patient uptake were highlighted as potential problems. More research is required to establish the benefits, drawbacks and nature of therapeutic time. Given the current support for the approach and previous research emphasizing the extent to which patients value protected time to speak to nurses, investment of resources in further exploration and implementation of this approach may lead to significant clinical returns.

Being informed and involved in treatment: what do psychiatric patients think? A review

Aims – A narrative review of studies on the information needs of psychiatric patients, the knowledge of their diagnosis and treatment expectations. Methods – A literature review, limited to studies between 1980 to 2003, was carried out using Medline and Psychlnfo databases. Results – Sixty five studies of interest were identified. Less than half of the psychiatric patients know their diagnosis and patients affected by schizophrenia are the least informed. Notions about aetiology and treatment are patchy, and the concept of ‘multifactorial cause’ seems unknown. Little knowledge emerged about drugs and side effects, expecially in the long term. Patients want to be informed, involved in decisions and their treatment programme. They feel that their psychiatrists are more interested in pharmacological aspects than in their personal problems. Conclusions – A better quality of communication, the involvement of patients in decision processes and meeting patients' information needs is necessary to improve therapeutic relationships, to encourage greater compliance with treatment programs and to reduce the stigma of psychiatric illness.

Declaration of Interest: none of the three authors has had any interest or received any form of support, including that from drug companies and honoraria for lectures and consultancies, potentially in conflict with this scientific work.

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force's findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.

Patient opinions on the helpfulness of external rehabilitative activities in residential psychiatric care: a pilot study

INTRODUCTION

This study explores the patient opinions about the helpfulness of the External Rehabilitative Activities (ERA) delivered in two residential facilities for psychiatric rehabilitation.

METHODS

We administered a Questionnaire developed to assess general helpfulness, helpfulness of specific therapeutic processes and satisfaction with the ERA to a sample of 46 psychiatric patients participating in at least three external activities.

RESULTS

The External Rehabilitative Activities, tested by the ERA-Questionnaire, were considered helpful or very helpful by most of the patients. The therapeutic process with the highest score was "relaxation", followed by "general helpfulness", "socialization", "knowledge of social context", "community integration". The least-valued process was "autonomy".

CONCLUSION

This pilot study has shown that psychiatric patients consider ERA helpful and rate more helpful the specific therapeutic processes, such as relaxation and socialization, that assure symptomatic relief and interaction with the outside world.

What was good about admission to an aged psychiatry ward? The subjective experiences of patients with depression

BACKGROUND

The treatment of depression in Australian aged psychiatry units has been found to be effective in terms of symptom improvement and readmission rates. There is little information, however, about how such hospitalization is viewed by the patients themselves. While users' views are increasingly seen as important for the evaluation of mental health services and for improving outcomes, the views of older patients are less likely to be sought. In this study, former patients were asked about their experience of admission, which aspects were helpful and which were not. Negative experiences have been described in an earlier paper. This paper focuses on what study participants considered to be the positive aspects of their time in hospital.

METHODS

Fifty former patients from three Melbourne hospitals were interviewed in their own homes using a semi-structured, open-ended questionnaire.

RESULTS

Forty-six percent expressed an overall favorable view of their hospital stay; 34% had some reservations; and 20% had a poor overall view. Favorable views did not necessarily preclude distressing incidents or complaints but were associated with the ward environment, experienced as a safe haven; the re-evaluation of negative experiences; and, in most but not all cases, recovery.

CONCLUSIONS

Retrospective accounts are useful for understanding the ways in which hospital experience is processed. Remembering the experience as positive is, in itself, a good therapeutic outcome. In addition, it may influence readiness to seek future treatment, help prevent relapse, and, indirectly, be helpful to others with similar problems.

Patients' perceptions of the concept of the quality of care in the psychiatric setting: a phenomenographic study

AIM

The aim was to describe how patients perceived the concept of quality of care in psychiatric care.

BACKGROUND

It is important to include patients' experiences in defining quality of care and in the development of instruments measuring quality of psychiatric care, as patients have unique information. But only a limited number of studies have directly involved patients.

DESIGN

It was a qualitative interview study with 20 adult in and outpatients from psychiatric care.

METHOD

A phenomenographic approach was used for the analysis of the interviews.

RESULTS

The results showed that quality of care was perceived as a positive concept, namely as 'good' quality of care. The normative component was striking. Five descriptive categories emerged: The patient's dignity is respected; The patient's sense of security with regard to care; The patient's participation in the care; The patient's recovery; and The patient's care environment. Two conceptions emerged that had not emerged explicitly in earlier studies of quality of care: Being helped to reduce the shame and Being looked upon as like anyone else.

CONCLUSIONS

The findings emphasize the importance of the interpersonal relationship between patients and staff. There is a need for further exploration of central aspects of quality in psychiatric care.

RELEVANCE TO CLINICAL PRACTICE

It is important that the knowledge about how patients perceived the quality of care in psychiatric care is included in the planning and evaluation of care. The guidelines should designate quality of care from the patient perspective as the goal of interventions.

Background factors as determinants of satisfaction with care among first-episode psychosis patients

OBJECTIVE

To evaluate the impact of demographic and psychosocial background factors and psychiatric and functional status before and at admission on the patients' satisfaction with care (PSC) among first-episode psychosis (FEP) patients.

METHOD

One year after entering the Parachute Project, 134 FEP patients completed a patient satisfaction questionnaire. The association with demographic and psychosocial background factors, together with psychiatric and functional status before and after admission, was analysed.

RESULTS

Twenty-nine per cent of the variance of PSC was explained by factors such as educational level, social network, duration of untreated psychosis (DUP) and Global Assessment of Functioning (GAF) the year prior to onset. Negative symptoms and lack of hope at admission were also predictors of PSC. The strongest predictor was DUP.

CONCLUSION

Affecting the public knowledge in psychiatric problems and psychiatric treatment, together with early intervention strategies aiming to decrease the prodromal and DUP period among FEP patients, can positively influence the patients' experience of given care. By increasing the knowledge of available psychiatric treatment, the sense of powerlessness might decrease among the affected persons, and the possibility of early help seeking might increase.

Patient opinions on the benefits of treatment programs in residential psychiatric care

OBJECTIVE

To assess patients' opinions on the perceived benefit of treatment delivered during their stay in a residential facility.

METHOD

We administered the Opinions on Curative Factors Questionnaire (OCFQ), which was developed from previous studies and assesses several treatment modalities and therapeutic factors, to a sample of 157 severely ill psychiatric patients admitted to a residential facility.

RESULTS

All therapeutic factors tested by the OCFQ were considered helpful or very helpful by most of those sampled. The item with the highest score was "talking to doctor," followed by "free pass," "medication," "visitors," "nonhospital setting," "making friends with patients," "structure of daily life," "support from team," and "talking to nurses." The least-valued item was "group activities."

CONCLUSION

Psychiatric patients consider several treatment factors to be helpful, especially those based on individual approaches or on a less restrictive therapeutic milieu that allows interactions with the outside world. These results may be a valuable contribution to improving treatment planning in residential facilities.

Adolescents with mental health problems: what do they say about health services?

This study explored the health-related views and experiences of adolescent users of mental health services through semi-structured interviews with 32 14-20-year olds who had been diagnosed with a mental illness. The majority of respondents had both negative and positive things to say about their contact with health services. These relate to: the doctor-patient relationship, treatment received, the health-care system, and the environs of the hospital or clinic. The views and experiences of young people with regard to their health care must be taken into account in efforts to boost help-seeking, attendance and compliance rates and, generally, to improve child and adolescent mental health services. In particular, further attention needs to be given to the development of empathic communication skills by health professionals working with adolescents with mental health problems. Work on the health-related views and experiences of representative samples of young people with mental health problems should be prioritized.

Challenging contemporary mental health policy: time to assuage the coercion?

BACKGROUND

In the United Kingdom (UK) and elsewhere throughout the world, the policy and legal frameworks that surround the provision of mental health care are becoming increasingly coercive. For example, emerging mental health policy in the UK includes a commitment to the introduction of compulsory treatment in the community.

AIMS

In this paper, our aims are: to explore the context in which this more coercive mental health policy has arisen in the UK; to challenge the assumptions and the evidence that lie behind the introduction of proposed new mental health policies; and to consider the impact that a more coercive policy is likely to have on the practice of mental health nursing.

DISCUSSION

In the UK, representatives of central government have declared that 'care in the community has failed'. This view has been reinforced by media representations of mental health issues. Policy documents have drawn attention to the risks posed by people with mental illnesses. Correspondingly, proposed initiatives emphasize the need to more closely 'manage' people with mental health problems, and set out a new legislative and policy framework to achieve this. We question the assumptions and evidence that underlie these planned new developments. We argue that, contrary to government assertions, there is no unequivocal evidence that 'community care' has failed. We observe, too, that people with mental health difficulties are often amongst the most vulnerable members of society. Finally, we consider the impact that a more coercive policy framework will have on the work of mental health nurses, and argue that the shift towards a more 'controlling' role is likely to run counter to what many nurses see as the 'core' of their work.

Consumer issues in navigating health care services for type I diabetes

Despite increasing interest in consumer awareness and participation in health care service delivery, there has been little exploration of consumer views in relation to services for people with type I diabetes. The purpose of this qualitative exploratory study was to identify strategies people with type I diabetes used to access health services and the barriers they perceived in accessing the services they needed. Data gathered in semi-structured interviews revealed that consumers experience significant barriers when navigating the health care system. Three dominant themes were identified. They relate to access to specialist medical skill, to the transition from teenager to young adult and to pre-pregnancy and obstetric care. Directions for change in service delivery and policy development are discussed.

The commonality and synchronicity of mental health nurses and palliative care nurses: closer than you think? Part two

This is the second of a two-part paper which explores the areas of commonality and synchronicity between palliative care (PC) nurses and mental health nurses. The authors argue that this commonality is best articulated under the headings: defining the needs of the client group, the role of the nurse in non-physical care, the nurse--client relationship, and the locus of control. They also argue that the differences between these groups of nurses are best articulated under the headings: facilitation/confrontation and the focus on physical care. Part one focused on the first three areas of commonality, whereas this paper focuses on the fourth commonality, the locus of control. It also focuses on key differences and the implications of such similarity. The paper highlights the practice, education and research implications of this alleged commonality. It suggests, given the evidence that clients perceive the therapeutic relationship as the vital and unique aspect of PC nursing, that those working within palliative care need to question whether or not RGN registration is an essential requirement, or whether those with other skills, such as psychiatric/mental health (P/MH) nurses, should be considered for such roles. It highlights the need for the provision of post-basic counselling courses and the potential value for PC nurses of receiving clinical supervision from P/MH nurses or mental health liaison nurses. Lastly, it posits that the research issues arising out of this alleged commonality centre on the potential impact such transitions in care delivery may have on the care delivered, on the nurses themselves and on the clients.

The commonality and synchronicity of mental health nurses and palliative care nurses: closer than you think? Part one

The role of the palliative care nurse emphasizes the need for holistic care, and as this role has developed it has become evident that palliative care nurses require skills which, arguably, not all registered general nurses possess; particularly, skills pertaining to the psychological, social and spiritual domains of the person. In order to identify the skills that such nurses may require, there may be merit in considering other specialities of nursing which pay particular attention to the psychological, social and spiritual domains of the person. Consequently, this two-part paper explores the areas of commonality and synchronicity between palliative care nurses and mental health nurses. The authors argue that this commonality is best articulated under the headings: defining the needs of the client group, the role of the nurse in non-physical care, the nurse--client relationship, and the locus of control. They also argue that the differences between these groups of nurses are best articulated under the headings: facilitation/confrontation, and the focus on physical care. Part one of this paper therefore focuses on the first three areas of alleged commonality, with part two focusing on the fourth commonality, the key differences and the implications of such similarity. Given these areas of similarity the authors argue there is a case for reconsidering if the RGN qualification is an essential requirement for working within palliative care or if those with other skills -- skills based on 'being with' rather than 'doing for' -- such as RMNs, should be thought of for such roles.

Fit for purpose? Promoting the human side of mental health nursing

Currently, preparation of mental health (MH) nurses appears to emphasize tangible, highly visible skills acquisition. While few credible MH nurses would argue with the need for some acquisition of skills during nurse training, it is the emphasis on this acquisition of skills at the expense of the development of certain other qualities that is questionable. This article argues that the 'human side' of MH nursing should not be forgotten or ignored and draws attention to evidence of the invisibility of some aspects of MH nursing. It also draws attention to how 'human-focused' MH nursing practice may be inhibited by market forces, the pressures of economic restraints and the current preoccupation with 'quick-fixes'. It points out that within the field of psychiatry and MH care, there is evidence that some nurses have returned to 1930s neo-Darwinian perspectives of the mind. The article suggests that it is unlikely that current MH nurse training, with its emphasis on neurobiology and masculine approaches to care, adequately prepares MH nurses for ways of working which are described in this article as the 'proper focus of nursing'. Additionally, the article points out that a view of the development of MH nurse training that includes more training in psychotherapeutic approaches to care is not evidence of a fanciful, unrealistic or Utopian view of MH nurse preparation.

Mental health service user involvement in nurse education: exploring the issues

This paper reports on findings and issues arising from a study designed to promote mental health service users' involvement in a preregistration nursing curriculum. Users' views about the knowledge, skills and attributes required by mental health nurses were explored to inform the curriculum design. Strategies that would facilitate long term, active user involvement in the design and delivery of the curriculum were also explored. Findings are presented with concurrent discussion of issues arising from the research process in relation to user involvement in education. The issue of 'conflict' explores findings relating to users' views of a 'good' mental health nurse and inherent conflicts between user and professional views are highlighted. The representativeness of the research participants is explored and debated in relation to service user involvement in nurse education. Finally, the concepts of 'involvement' and 'tokenism' are discussed and recommendations made about how active user involvement in nurse education can be achieved.

Prediction of hospitalizations by schizophrenia patients' assessment of treatment: an expanded study

This study examines whether schizophrenia patients' global assessment of treatment predicts outcome in community care. Eighty-five patients rated the extent to which their treatment was right for them. The outcome measure was assessed by means of a hospitalization index reflecting the duration of full and partial hospitalization within a follow-up period of 24 months. Patients who dropped out (n = 21) assessed their treatment more negatively than those who remained in the care system during follow-up. Patients with no hospitalization (n = 25) expressed a more negative assessment than patients who were hospitalized in the follow-up period at least once (n = 39). In this latter subgroup, however, patients with a more negative assessment had a longer duration of hospitalization during follow-up, and patients' assessment of treatment was the best single predictor of outcome (r = -0.50, P < 0.01). In a multiple regression analysis, patients' assessment of treatment, the number of previous hospitalizations and the hospitalization index in the two years prior to the interview, together, explained approximately half of the variance of outcome (adjusted R2 = 0.46). The findings underline the relevance of asking patients whether treatment is right for them, although the relationship between patients' assessment of treatment and long-term outcome seems more complex than previous studies suggested.

User involvement in the nursing curriculum: seeking users' views

This qualitative study considers the views of users of mental health services on a pre-registration nursing curriculum. Semistructured group interviews were used to gain the (illustrative) views of twenty members of two user groups on nursing knowledge, skills and qualities. Interest in users' views has generally been belated or reluctant. In more recent literature, statements emerge about the need to develop a climate of respect, acceptance and sensitivity. While nurses have a central role in mental health care, a detailed examination from the user's perspective has been lacking. Despite the rhetoric of involvement, commentaries on nursing practice suggest little has changed. Findings suggest an eclectic knowledge base that respects individual differences and the user's experience, knowledge of local communities, and better recognition of physical illness is required. 'Knowledge of life' is seen as important. An emphasis on interpersonal skills is suggested, including flexible responses, information-giving, and sensitive handling of tense situations. This should be balanced against 'practical' nursing. Traditional teaching in relation to 'psychotic' experiences is challenged. It is suggested that caring should be emphasized as much as 'rational knowledge'. Developing responsive qualities that minimize 'distancing' may demand a reevaluation of boundaries between user and professional.

Using consumer feedback to improve services

Describes how a consumer satisfaction survey was carried out at a community mental health centre and the improvements that occurred as a result. A questionnaire was designed to be delivered as a semi-structured interview to elicit the views and opinions of the clients. Their responses highlighted a number of positive areas about the centre, especially in terms of the staff and the therapeutic support they provide. The feedback also revealed a number of areas where improvements were needed. Reports on six recommendations which were made in terms of medication, activities, privacy, reviews, social service issues and complaints. The staff worked hard to implement a number of changes to improve the quality of the service they provide. The end result is that users' views and opinions have been integrated with the service design and delivery, making the centre a more user-friendly place.

User satisfaction with in-patient mental health services

Although a wealth of literature regarding lay evaluation or satisfaction with health services exists, a paucity of literature is available about satisfaction with mental health services. Much of this literature is fraught with methodological problems. The study described, using both quantitative and qualitative methodology, investigated how users of in-patient mental health services evaluated these services with particular reference to the areas of the admission process, treatment, ward environment and safety. The findings confirmed the broad outcomes reported in the literature, in that they demonstrated the mismatch between quantitative and qualitative data. Global satisfaction ratings were generally positive; however, more specific questions yielded less positive outcomes. Semi-structured interviews reported some important areas of dissatisfaction, including a lack of information regarding treatment and services. Fears relating to safety were expressed equally by male and female users. Further work in this area is required with larger samples, and with specific reference to the experience of ethnic minorities and those detained under the Mental Health Act.

Marketing the mental health care hospital: identification of communication factors

The current study provides guidance to hospital administrators in their effort to develop more effective marketing communication strategies. Two types of communication factors are revealed: primary and secondary. Marketers of psychiatric hospitals may use the primary factors as basic issues for their communication campaign, while secondary factors may be used for segmentation or positioning purposes. The primary factors are open wards, special treatment for adolescents, temporary absence, while patient, in-patient care, and visitation management. The secondary factors are temporary absence while a patient, voluntary consent to admit oneself, visitation management, health insurance, open staff, accreditation, physical plant, and credentials of psychiatrists.

Perceived importance of caring behaviors to Swedish psychiatric inpatients and staff, with comparisons to somatically-ill samples

The present study identified psychiatric inpatient (N = 61) and staff (N = 63) perceptions of most and least important nurse caring behaviors using a modified Swedish version of the CARE-Q instrument (Larson, 1981) and compared the results with data from somatic care (von Essen & Sjödén, 1991a, 1991b). The results demonstrated 13 significant mean between-group differences in the rating of 50 specific CARE-Q behaviors. Two significant mean value differences out of six subscales combining individual items were demonstrated between groups. Psychiatric inpatients considered the cognitive aspect, and somatic inpatients the task-oriented aspect of caring as the most important. Staff, in psychiatric as well as somatic care, considered the emotional aspect of caring as the most important. The results suggest that staff has a relatively invariant, human-oriented perception of caring, irrespective of subdisciplines, while patients' perceptions of caring vary more over specialties.

The concept of recovery and secondary prevention in psychotic disorders

The concept of recovery is embedded in the current classification of functional psychosis, an unfortunate fact which has obscured important therapeutic and preventive opportunities for patients and their relatives. A range of theoretical perspectives is reviewed which could be drawn upon to extend research, and develop and evaluate new forms of intervention in this area. The major tasks facing patients and their families at different stages of illness are described, and a series of principles is then proposed to guide the clinical care of recovering psychotic patients.

Some aspects of family interventions in schizophrenia. II: Financial considerations

The direct costs to the mental health services for patients who participated in a trial of a behavioural family intervention to reduce schizophrenic relapse were estimated. Comparisons were made between two patient groups from households of high expressed emotion (HEE): one group received a nine-month family intervention (HEE Intervention) and the other group routine treatment (HEE Control). A third group consisted of patients from low-EE households (LEE Control). The significant decrease in relapse rates in the HEE Intervention group compared with the HEE Control group has previously been reported; the analysis of costs indicates that any increase in costs due to the family intervention is outweighed by a decrease in usage of the established mental health services. The intervention resulted in a decrease of 27% in mean cost per patient.