Collaborative Care for Patients With Severe Personality Disorders: Preliminary Results and Active Ingredients From a Pilot Study (Part I)

Subtyping Service Receipt in Personality Disorder Services in South London: Observational Validation Study Using Latent Profile Analysis

BACKGROUND

Personality disorders (PDs) are typically associated with higher mental health service use; however, individual patterns of engagement among patients with complex needs are poorly understood.

OBJECTIVE

The study aimed to identify subgroups of individuals based on patterns of service receipt in secondary mental health services and examine how routinely collected information is associated with these subgroups.

METHODS

A sample of 3941 patients diagnosed with a personality disorder and receiving care from secondary services in South London was identified using health care records covering an 11-year period from 2007 to 2018. Basic demographic information, service use, and treatment data were included in the analysis. Service use measures included the number of contacts with clinical teams and instances of did-not-attend.

RESULTS

Using a large sample of 3941 patients with a diagnosis of PD, latent profile analysis identified 2 subgroups characterized by low and high service receipt, denoted as profile 1 (n=2879, 73.05%) and profile 2 (n=1062, 26.95%), respectively. A 2-profile solution (P<.01) was preferred over a 3-profile solution, which was nonsignificant. In unconditional (t3941,3939=19.53; P<.001; B=7.27; 95% CI 6.54-8) and conditional (t3941,3937=-3.31; P<.001; B=-74.94; 95% CI -119.34 to -30.56) models, cluster membership was significantly related to receipt of nursing contacts, over and above other team contacts.

CONCLUSIONS

These results suggest that routinely collected data may be used to classify likely engagement subtypes among patients with complex needs. The algorithm identified factors associated with service use and has the potential to inform clinical decision-making to improve treatment for individuals with complex needs.

Towards collaborative care for severe and enduring Anorexia Nervosa - a mixed-method approach

BACKGROUND

Severe and Enduring Eating Disorders (SEED), in particular SEED-Anorexia Nervosa (SE-AN), may represent the most difficult disorder to treat in psychiatry. Furthermore, the lack of empirical research in this patient group, and, consequently the lack of guidelines, call for an urgent increase in research and discussion within this field. Meanwhile experts concur that effective care should be structured in a collaborative manner.

OBJECTIVE

To identify the challenges in providing care to patients with SE-AN in the Dutch healthcare context, and propose a collaborative care treatment model to address these issues.

METHODS

A pragmatic mixed-method approach was used, structured as follows: (1) Identifying perceived barriers and treatment needs from the viewpoint of both patients and eating disorder healthcare professionals through an evaluation questionnaire; (2) Investigating current treatment practices for SEED/SE-AN via benchmarking; (3) Gaining insight into the optimal structure and content of care by interviewing network partners and experts-by-experience. Based on these findings, and drawing from literature on severe and enduring disorders, a treatment model for SE-AN was proposed and implemented.

RESULTS

The key challenges identified included a lack of knowledge about eating disorders among network partners, treatment ambivalence among patients and poor collaboration between professionals. The proposed model enhances self-management and collaborative relationships with healthcare providers, offers user-friendly and practical guidance, and aims at stabilization, reducing relapses, deterioration, and readmissions, thereby being cost-effective. Importantly, the model operates across levels of care (primary, secondary, tertiary).

CONCLUSION

This study, describing a collaborative care program for SE-AN, developed and implemented in a highly specialized treatment center for eating disorders, sets the stage for further explanatory/efficacy research to build on the findings in this study, with the following aims: addressing the critical gap in care for SEED/SE-AN, improving better healthcare organization, reducing relapse rates, and lowering costs for this often overlooked patient group.

Perspectives of nurses' role in interprofessional pharmaceutical care across 14 European countries: A qualitative study in pharmacists, physicians and nurses

OBJECTIVES

To understand healthcare professionals' experiences and perceptions of nurses' potential or ideal roles in pharmaceutical care (PC).

DESIGN

Qualitative study conducted through semi-structured in-depth interviews.

SETTING

Between December 2018 and October 2019, interviews were conducted with healthcare professionals of 14 European countries in four healthcare settings: hospitals, community care, mental health and long-term residential care.

PARTICIPANTS

In each country, pharmacists, physicians and nurses in each of the four settings were interviewed. Participants were selected on the basis that they were key informants with broad knowledge and experience of PC.

DATA COLLECTION AND ANALYSIS

All interviews were conducted face to face. Each country conducted an initial thematic analysis. Consensus was reached through a face-to-face discussion of all 14 national leads.

RESULTS

340 interviews were completed. Several tasks were described within four potential nursing responsibilities, that came up as the analysis themes, being: 1) monitoring therapeutic/adverse effects of medicines, 2) monitoring medicines adherence, 3) decision making on medicines, including prescribing 4) providing patient education/information. Nurses' autonomy varied across Europe, from none to limited to a few tasks and emergencies to a broad range of tasks and responsibilities. Intended level of autonomy depended on medicine types and level of education. Some changes are needed before nursing roles can be optimised and implemented in practice. Lack of time, shortage of nurses, absence of legal frameworks and limited education and knowledge are main threats to European nurses actualising their ideal role in PC.

CONCLUSIONS

European nurses have an active role in PC. Respondents reported positive impacts on care quality and patient outcomes when nurses assumed PC responsibilities. Healthcare professionals expect nurses to report observations and assessments. This key patient information should be shared and addressed by the interprofessional team. The study evidences the need of a unique and consensus-based PC framework across Europe.

"People just don't understand their role in it." Collaboration and coordination of care for service users with complex and severe mental health problems

PURPOSE

To explore professionals' and service users' experiences and perceptions of interprofessional collaboration and coordination for service users with complex and severe mental health issues.

DESIGN AND METHODS

A qualitative study involving semi-structured interviews of professionals and individual interviews of service users. Data were analyzed by thematic analysis.

FINDINGS

Participants described challenges and suggested improvements concerning Distribution of roles, responsibilities, and tasks; Communication; and Knowledge and attitudes.

PRACTICE IMPLICATIONS

Mental health nurses and other professional helpers should have a particular focus on common aims, clear division of roles, planning and timing of interventions, and communication with other professionals and service users.

Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Background

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

Objectives

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Design

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Results

Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: In many countries, the majority of psychiatric care is being delivered in an outpatient setting and the proportion of outpatients is increasing on a global level. Nurses are the largest workforce in psychiatric care, but their role has been said to be difficult to define. According to our knowledge, there are no previous reviews focusing on nurse-delivered interventions in the adult psychiatric outpatient setting. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review summarizes nurse-delivered interventions identified in the research literature and describes these systematically. Analysing all the identified interventions using the Nursing Interventions Classification, we conclude that the emphasis of nurse-delivered interventions in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from those presented in a review on inpatient psychiatric nursing. There are several clinical trials describing nurse-delivered evidence-based treatments, such as psychoeducation for patients and their family members in the case of patients diagnosed with schizophrenia and bipolar disorder. The quality of randomized controlled trials was higher than in earlier reviews describing psychiatric nursing interventions in general or in connection with a specific patient group. Further clinical trials are needed to describe the role of nurses in the care of patients diagnosed with depression and in the use of web-based interventions. Additionally, it would be important to study what supports, and on the other hand hinders, the role of nurses in delivering evidence-based treatments at the clinical level. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses can play a central role in responding to the growing demand for evidence-based practices in adult outpatient psychiatry, by delivering treatments for patients and family members. It is important that both nursing education and clinical practices recognize and support this role. Abstract Introduction According to our knowledge, there are no previous reviews on nurse-delivered interventions in the adult psychiatric outpatient setting. Aim To identify and systematically describe and analyse nurse-delivered interventions based on research literature. Method An integrative review. Results This review included 60 studies, of which 46 were intervention studies, including 40 clinical trials. The most common patient groups were patients diagnosed with schizophrenia and bipolar disorder. The nursing interventions described in the studies resembled a total of 68 interventions from the Nursing Interventions Classification. The treatment delivery methods varied and treatments often lacked a clear theoretical background. Implications for practice The core of nurse-delivered interventions identified in research literature in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from the interventions identified in a review describing nursing in the inpatient setting. There are high-quality clinical trials describing nurse-delivered treatments for patients diagnosed with schizophrenia and bipolar disorder. These include evidence-based treatments such as psychoeducation. Understanding of how these treatments are transferred in clinical practice is missing. Clinical trials describing nurse-delivered web-based interventions and interventions for patients diagnosed with depression are needed.

Carer perspectives of people diagnosed with borderline personality disorder: A scoping review of emergency care responses

BACKGROUND

Caring for a person with borderline personality disorder remains largely stigmatised and misunderstood. When a crisis arises, carers often seek help with the person they care for in emergency care settings such as the emergency department. The aim of this review was to explore, locate and compile the literature regarding the perspectives of family carers for a person with borderline personality disorder in an emergency care setting with a focus on nursing practices. This review advances understandings of carer perspectives in emergency care settings.

METHODS

The Joanna Briggs Institute (2015) [1], methodology for scoping reviews guided this review. A search of Emcare, Medline and Ovid Nursing was performed during April 2018, to identify literature where carer views and perspectives on engaging with emergency care services were reported. A grey literature search was also conducted. A total of ten articles and reports were included in this review. Consultation with a carer support group precipitated this review, which assisted in the formulation of the research questions.

RESULTS

Papers found via the study focused on health professional responses, rather than on nursing practice. Findings indicate that carers often perceive emergency departments as the only option for emergency care in a crisis. Carers require information about how to effectively manage a crisis with their loved one more effectively.

CONCLUSION

This scoping review identified that carers are often not consulted or engaged with by health professionals. Carers often perceive that nurses and health professionals have a lack understanding about the consumer's conceptualisation of distress and the nature of BPD, which becomes a barrier to effective crisis support and management. The literature often reported that a trusting and collaborative relationship between carers, nurses and health professionals demonstrated improved outcomes for the carer and consumer.

Adaptation of a scale to measure coping strategies in informal primary caregivers of psychiatric patients

WHAT IS KNOWN ON THE SUBJECT?: Informal caregivers of psychiatric patients are vulnerable to many disturbances associated with the stress related to their activity. Caregivers who show a coping style focused on problem-solving report less psychological distress, and this approach positively influences the recovery process of the psychiatric patient. There are some questionnaires to measure coping styles in caregivers of psychiatric patients, but most of them do not have the minimum psychometric properties that a scale must fulfil. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The authors present an adapted and validated scale for measuring both active and passive coping strategies used by informal caregivers to face daily stressful situations with psychiatric patients. The study is an example of how scales can be adapted to small samples (n < 200). WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The scale could be helpful for generating strategies to support the family caregiver, as well as for measuring the results of interventions. The scale could also be used to identify how coping styles of informal caregivers are related to recovery process of psychiatric patients.

ABSTRACT

Background The recovery process of a psychiatric patient is related to his primary informal caregiver's style of coping with stress. There is insufficient literature on validations of instruments that measure coping styles in this population. Objective To adapt and validate a scale to measure coping strategies in primary informal caregivers. Method The adapted scale was based on the Extreme Coping Scale of López-Vázquez and Marván. Items from that scale were adapted for application to informal caregivers. The scale was administered to 122 primary informal caregivers of patients from two psychiatric institutions in Mexico. Psychometric analyses were performed to determine the scale's properties. Results The scale was composed of 20 items (six less than in the original scale) and two factors: (i) active coping (Cronbach's alpha = .837) and (ii) passive coping (Cronbach's alpha = .718). Discussion The findings are discussed in the light of the importance of studying the relationship between coping styles and the well-being of both informal caregivers and psychiatric patients. Implications for practice The scale could be used by health practitioners and researchers to generate strategies to support the family caregiver, as well as to measure the results of interventions.

Collaborative Care for Patients With Severe Personality Disorders: Analyzing the Execution Process in a Pilot Study (Part II)

PURPOSE

To examine the factors that influence the effective execution of a collaborative care program (CCP) for patients with severe personality disorders.

DESIGN AND METHODS

A multiple case study using qualitative research methods.

FINDINGS

Three factors were identified as influencing the execution process: (a) the context in which the CCP was executed, (b) the patient population, and (c) the individual application of the CCP by nurses.

PRACTICE IMPLICATIONS

The prominent position of mental health nurses in complex intervention programs such as CCPs poses new challenges for them in making these programs work. A CCP could be a useful intervention for patients with severe personality disorders because it offers the necessary structure in treatment.