Moral decision-making among assertive community treatment (ACT) case managers: a focus group study

Towards machine learning for moral choice analysis in health economics: A literature review and research agenda

BACKGROUND

Discrete choice models (DCMs) for moral choice analysis will likely lead to erroneous model outcomes and misguided policy recommendations, as only some characteristics of moral decision-making are considered. Machine learning (ML) is recently gaining interest in the field of discrete choice modelling. This paper explores the potential of combining DCMs and ML to study moral decision-making more accurately and better inform policy decisions in healthcare.

METHODS

An interdisciplinary literature search across four databases - PubMed, Scopus, Web of Science, and Arxiv - was conducted to gather papers. Based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, studies were screened for eligibility on inclusion criteria and extracted attributes from eligible papers. Of the 6285 articles, we included 277 studies.

RESULTS

DCMs have shortcomings in studying moral decision-making. Whilst the DCMs' mathematical elegance and behavioural appeal hold clear interpretations, the models do not account for the 'moral' cost and benefit in an individual's utility calculation. The literature showed that ML obtains higher predictive power, model flexibility, and ability to handle large and unstructured datasets. Combining the strengths of ML methods with DCMs has the potential for studying moral decision-making.

CONCLUSIONS

By providing a research agenda, this paper highlights that ML has clear potential to i) find and deepen the utility specification of DCMs, and ii) enrich the insights extracted from DCMs by considering the intrapersonal determinants of moral decision-making.

"Modifying" or "Retreating"- Self-management of physical health among a group of people with schizophrenia. An ethnographic study from Denmark

The aim of this ethnographic study was to explore how a group of nine Danish people with schizophrenia managed physical health issues as they naturally occurred in everyday life. Qualitative methods were used to generate of data. Thematic analysis led to the description of two typical strategies used by participants to manage debilitating physical health issues in everyday life. Modifying everyday life to manage discomfort was a strategy employed to manage potential or actual discomfort associated with ongoing poor physical health, while retreating from everyday life to recover was a strategy used by participants who experienced recurring discrete episodes of poor physical health characterized by fast deterioration. Both management strategies were inexpedient as they failed to produce any positive progress in terms of the participants regaining health. The social context of participants' everyday life was characterized by a lack of interactions with others about their prevailing and ongoing physical health issues. Repeated use of these inexpedient strategies to manage physical health caused potential worsening rather than improvements to physical health. There is a need for future research that explores aspects of beneficial management of physical health issues among people with severe mental illness. Relevant foci of such research include enhancing self-management of physical health, active help-seeking behaviours, and opportunities to engage in interactions with others about physical health issues.

Barriers and Possible Solutions to Providing Physical Health Care in Mental Health Care: A Qualitative Study of Danish Key Informants' Perspectives

Provision of physical health care to people diagnosed with severe mental illness is widely reported as inadequate. This interview study explored perspectives of a group of key informants on current practices of providing physical health care within two mental health care settings in Denmark. Thematic analysis of their accounts provided insights into 1) barriers to the provision of physical health care in mental health settings, and 2) possible solutions to overcome existing barriers. Negative attitudes and limited specialist health care knowledge among mental health care professionals constituted serious barriers. To effectively address these barriers, mental health services need to be reoriented towards the prioritisation of physical health alongside mental health. This will require equipping mental health professionals with relevant knowledge and skills and organisational resources, to effectively work with people experiencing or at risk of physical comorbidities.

Responsibilities with conflicting priorities: a qualitative study of ACT providers' experiences with community treatment orders

Background

Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.

Methods

The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.

Results

The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.

Conclusions

Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.

Assertive community treatment (ACT) case managers' professional identities: A focus group study

Assertive community treatment (ACT) case managers provide healthcare services to people with severe and persistent mental illness. These case managers take on generic roles in multidisciplinary teams and provide all-around services in the clients' private homes. This focus group study aimed to gain insight into Danish ACT case managers' professional identity work by examining their discussions of ethical dilemmas and collaboration in their everyday practice. Data were collected during five focus groups at three ACT teams in the North Denmark Region and subjected to discourse analysis emphasizing how identity work was accomplished through talk. The findings indicated that the case managers constructed professional identities by actively positioning themselves and the particular ACT approach in relation to other mental healthcare professionals and clients. They represented themselves as achieving better client-related outcomes by being more assertive and persistent, and as responsible caregivers who provided the help that their clients needed when other services had failed to do so. They depicted their services as being focused on the clients' well-being, and their persistent efforts to establish and sustain interpersonal relationships with clients were an important part of their service. Basic nursing tasks were described as an important part of their everyday work, and even though such tasks were not distinctive for ACT case managers, the representations of their work seemed to give them a sense of worth as professionals and legitimized a unique role in the community mental healthcare services.