Recovery of Patient with Complex Needs - Essay Example

?Running Head: PROMOTING RECOVERY OF PATIENT WITH COMPLEX NEEDS Promoting Recovery of Patient with Complex Needs of the of the Institution] Promoting Recovery of Patient with Complex Needs Introduction In England and Wales, standards for mental health service provision are set out in National Service Frameworks (Department of Health, 1999; Welsh Assembly Government, 2005). These require that comprehensive and effective mental health services be delivered to people with severe and enduring mental health problems. It is challenging for services to engage with this client group, which, in addition to mental health problems, experiences difficulties relating to housing, employment, social exclusion and physical health. An increasing number of people in this group also have problems with substance misuse, often resulting in contact with the criminal justice system. These problems often interact and can appear intractable. Recent years have seen a paradigm shift in mental health, from a focus on illness and disability towards the promotion of recovery and social inclusion (Repper and Perkins, 2003). Underpinned by a stress vulnerability model of mental health problems (Zubin and Spring, 2004, 105; Nuechterlein, 2004, 300), a range of psychosocial interventions (PSI) can be used to enable service users to build on strengths and develop skills in order to manage their own mental health more effectively. This in turn can facilitate attainment by service users of socially valued roles and relationships taken for granted by most people. One of the available interventions is a structured approach to the prevention of relapse, developed by Birchwood and colleagues (Birchwood et al, 2000, 5), building on the early work of Herz and Melville (2006) and Birchwood himself (Birchwood et al, 2000, 652). This work had demonstrated that it was possible to predict relapse in psychosis on the basis of recognition of early warning signs. The intervention incorporates a strong educative element. This aims to increase understanding of the typically episodic nature of psychosis and to enhance service users' self-efficacy in relation to the management of their mental health. A Cochrane Review (Pekkala and Merinder, 2002) concluded that psychological education significantly reduces relapse rates, increases compliance with medication, and may have a positive effect on a person's well being. To deliver the relapse prevention intervention effectively calls for the use of a set of specialist knowledge and skills, in addition to general mental health nursing skills. Aims Our primary aim was to enhance the quality of service provided to users of the inpatient areas of the local mental health rehabilitation service by making the relapse prevention intervention available routinely and sustainably. An essential interim aim was to equip the multidisciplinary team with the knowledge, skills and confidence required to deliver the intervention effectively. To address these aims and evaluate whether they were achieved, we developed a project plan in six stages. In the event, workers from community settings also sought out the training, and so the original scope of the project was broadened to include all areas of the mental health rehabilitation service. This paper will focus on the aspects of the project relating to service users. Intervention The project was jointly led by the clinical nurse leader of the mental health rehabilitation services and a lecturer practitioner. At the outset we sought guidance from the Trust's research and development coordinator as to whether we should seek ethical approval for our planned project. The advice received was that the project represented service audit/evaluation rather than research and, as such, ethical approval was not required. We began by attending clinical meetings at which we described our plans and encouraged discussion and questions by the multidisciplinary team. We refined a previously developed two-day training programme in order to meet the needs of a multidisciplinary group of staff accustomed to working within a biomedical paradigm and with little, if any, training or experience in PSI. The training programme sought to link theory, evidence and practice. It emphasised collaborative working with service users in delivering the five-stage relapse prevention intervention described by Birchwood et al (2000). To develop the skills required to deliver the intervention effectively, a repeated sequence of modelling, rehearsal, review and feedback was used. The training programme was provided four times over a period of four months. We conducted an audit of the current provision of relapse prevention to service users in the inpatient areas, which consisted of two wards. This was done by examination of case notes. The information collected consisted of age; gender; ethnic origin; civil status; diagnosis; age on admission; duration of admission; whether there was regular family contact; whether there was input from any therapy services; and whether there was a relapse prevention plan. During the period when the training programme was taking place, we attended the clinical reviews that were held in order to ensure that PSI, including relapse prevention, were actively considered when discussing care management arrangements. As a means of bridging the gap between training and real-life practice, we organised for trained but inexperienced workers to co-work with a practitioner experienced in PSI. In addition, we set up ongoing group supervision for those who had completed the training: supervision has been identified as a crucial ingredient in achieving wider availability of PSI, by Fadden (2006) and Burbach and Stanbridge (2006) in relation to family interventions, and by Stevens and Sin (2005) in relation to PSI generally. One year after the training programme had been delivered for the final time, we carried out a follow-up audit. As we had extended the provision of training to workers from the community-based areas of the mental health rehabilitation service, we broadened the scope of the follow-up audit to include these. The audit again took the form of an examination of case notes and we collected additional, more qualitative information. If there was a relapse prevention plan, whether the service user's early warning signs had been identified; whether there was a detailed action plan; whether there was evidence that it had been collaboratively formulated; whether the service user had a copy. If there was no relapse prevention plan, whether this was because the service user had declined the offer of the intervention; and whether there was evidence that relapse prevention work had commenced but was unfinished. Outcomes As the training programme does not form the focus of this paper, we report its outcomes briefly. Total of thirty people attended. Of these, 12 were unqualified health care assistants, 16 were qualified nurses and two were medical staff. Twelve were from the inpatient areas, the remainder from other areas of the rehabilitation service. Evaluation of the training programme showed that the overwhelming majority had found it relevant, interesting and well-presented; that a great deal had been learned; and that they would recommend it to colleagues. Analysis of the impact of the training on knowledge, skills and confidence showed considerable gains in all areas. Our initial audit of the inpatient areas revealed a group of 30 middle-aged to more elderly service users, the majority of whom had a diagnosis of a psychotic disorder and whose duration of hospital stay averaged seven years. The women in the group (n=18) were older than the males (n=12) and tended to have been older when admitted to hospital. Two people were from minority ethnic backgrounds, a proportion roughly in line with the ethnic composition of the local population (Office for National Statistics, 2004). More than half (60%) had regular contact with family, while only one third received any input from therapy services. There was no evidence of relapse prevention work having been undertaken with any of the group. Although there had been changes within the mental health rehabilitation services in the intervening period, our follow-up audit showed a similar demographic picture to our baseline audit: a group of 27 middle-aged to more elderly service users, the majority of whom had a diagnosis of psychotic disorder and whose duration of hospital stay averaged six years. The women in the group (n=15) were again older than the males (n=12) and tended to have been older when admitted to hospital. Minority ethnic representation was similar. The case notes of two service users contained relapse prevention plans, but did not identify early warning signs, did not contain a detailed action plan and did not appear to have been developed collaboratively. Our audit of the community areas of the rehabilitation service at the time of the follow-up audit of the inpatient areas revealed a group of 39 service users, two thirds of whom were men: the male to female ratio (2:1) was distinctly different from that in the inpatient group (2:3 baseline, 4:5 follow-up). The vast majority had a diagnosis of psychotic disorder. On average, the group was some 10 years younger, but had had prolonged periods of contact with mental health services, 22 years on average since first contact. The proportion from minority ethnic backgrounds was 5%, slightly lower than that of the local population. The case notes of 12 service users contained relapse prevention plans, and there was evidence that relapse prevention work was underway with a further eight service users and that two service users had declined the offer of carrying out the work: this represented 56% of the total client group. In terms of our audit of the qualitative aspects, ten relapse prevention plans described the service user's relapse signature, based on early warning signs; seven contained detailed action plans; 11 showed evidence of having been collaboratively developed; seven contained evidence of the service user holding a copy of the plan. Discussion Our repeat audit showed marked differences between the inpatient areas and the community areas in the degree to which implementation of the intervention had taken place. The service users on the two wards concerned were some 10 years older on average than those in the community areas, and many had high levels of personal care needs. The service users in the community areas, however, were also characterised by an early age of onset, lengthy duration of contact with services, and diagnosis of serious and enduring mental illness. In terms of mental health, therefore, as a group they were not dissimilar to the service users in the inpatient areas. This raises questions about the reasons for the variation. It has been shown that the general interpersonal skills of mental health nurses are significantly better than the specific cognitive therapy skills that are required for PSI (Devane et al, 2003, 254). It has also been demonstrated that mental health nurses can be trained to deliver PSI with beneficial effects on outcomes for service users (Lancashire et al, 2004, 3941). Training alone is insufficient however, and since the introduction of PSI training for mental health workers in the early 1990s concerns have been expressed repeatedly about the implementation of PSI in routine practice (for example, Fadden, 2005, 600; Tarrier et al, 1999, 570; Brooker, 2001, 18; Fadden, 2006, 25). Tarrier et al (1999) identified organisational barriers as impeding the introduction and maintenance of skills developed through training. Fadden (2006) also recognised organisational factors, interacting with factors relating to service users and their families, and factors relating to the clinicians, as important influences on the delivery and receipt of family interventions. Diffusion of innovation theory (Rogers, 1995) may offer some insights into the variation in implementation following training in our project. The theory describes two types of social systems: heterophilous, which are receptive to change, and homophilous, which tend to resist people and ideas that differ from the system's norms. Rogers argued that the successful diffusion of innovations depends on whether the opinion leaders within the social system are seen to adopt the innovation. The influence of opinion leaders may promote or inhibit change. Greenhalgh et al (2004) noted that little more than indifference on their part may be required to inhibit the spread of innovation. In our project, despite our best efforts, we were unable to recruit either of the ward managers to undertake the training, to engage in relapse prevention work as coworkers, or to become involved in clinical supervision. In homophilous systems, opinion leaders who embrace change are likely to be regarded with suspicion: they may tend to avoid innovation in order to protect their status as opinion leaders (Rogers, 1995). By contrast, in the community areas, training and supervision was taken up by all grades of staff, including those in leadership roles. It is also possible that those more likely to adopt innovative ways of working had opted to work in a less hierarchical environment. Conclusions Greenhalgh et al (2004) formulated a conceptual model that described the determinants of diffusion, dissemination and sustainability of innovations in health service delivery. They suggested a two-stage framework for applying the model. In the first stage, as well as the innovation itself and the planned programme for its dissemination and implementation, consideration should be given to the characteristics of the environment, the organisation, the intended adopters and the opinion leaders. In the second stage, a pragmatic approach is recommended, in which the possible interaction between these factors in a particular local setting is considered. This illustrates the complexity of implementing PSI in routine practice, a point reinforced by the case studies outlined by Rayner et al (2007): as with our project, these all demonstrated partial successes in the implementation of PSI. Our primary aim was to make the relapse prevention intervention available routinely and sustainably. We were partially successful in achieving this. Important factors affecting the degree of our success, in the context of the model proposed by Grenhalgh et al. The intended adopters and opinion leaders have been located in the categories identified by Rogers (1995): innovators, early adopters, early majority, late majority, and laggards. When approaching the challenge of implementing innovative interventions in mental health service organisations, greater success might be achieved if factors that are likely to inhibit change are identified at an early stage and appropriate action taken to mitigate these. Reference Birchwood M, Spencer E, McGovern D (2000) Schizophrenia: early warning signs. Advances in Psychiatric Treatment 6: 93-101. Birchwood M, Smith J, Macmillan F, Hogg B et al (2000) Predicting relapse in schizophrenia: the development and implementation of an early signs monitoring system using patients and families as observers. Psychological Medicine 19: 649-56. Brooker C (2001) A decade of evidence-based training for work with people with serious mental health problems: progress in the development of psychosocial interventions. Journal of Mental Health 10(1): 17-31. Burbach F, Stanbridge R (2006) Somerset's family interventions in psychosis service: an update. Journal of Family Therapy 28: 39-57. Department of Health (1999) A national service framework for mental health. Department of Health: London. Devane SM, Haddock G, Lancashire S, Baguley I et al (2003) The clinical skills of community psychiatric nurses working with patients who have severe and enduring mental health problems: an empirical analysis. Journal of Advanced Nursing 27: 253-60. Fadden G (2005) Implementation of family interventions in routine clinical practice following staff training programs: a major cause for concern. Journal of Mental Health 6(6): 599-612. Fadden G (2006) Training and disseminating family interventions for schizophrenia: developing family intervention skills with multi-disciplinary groups. Journal of Family Therapy 28: 23-38. Greenhalgh T, Robert G, Bate P, Kyriakidou 0 et al (2004) How to spread good ideas: a systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. National Co-ordinating Centre for NHS Service Delivery and Organisation: London. Herz M, Melville C (2006) Relapse in schizophrenia. Journal of Psychiatry, Pg 801-12. Lancashire S, Haddock G, Tarrier N, Baguley I et al (2004) The impact of training community psychiatric nurses to use psychosocial interventions with people who have severe mental health problems. Psychiatric Services Pg 3941. Nuechterlein KH (2004) Vulnerability models for schizophrenia: state of the art: In: Hafner H, Gattaz W, Jangerik W (Eds). Searches for the cause of schizophrenia. Springer-Verlag: Berlin: 297-316. Office for National Statistics (2004) Census 2001 National Report for England and Wales Part 2. The Stationery Office: London. Pekkala E, Merinder L. (2002) Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews: Issue 2. Rankin J, Regan S (2004) Meeting complex needs: the future of social care. Turning Points/Institute of Public Policy Research: London. Rayner L, Young N, O'Carroll M (2007) Psychosocial interventions: implementation in practice: In: Stickley T, Basset T (Eds). Teaching mental health. John Wiley and Sons: Chichester. Repper J, Perkins R (2003) Social Inclusion and Recovery: a model for mental health practice. Balliere Tindall: Edinburgh. Rogers E M (1995) Diffusion of innovations (4th Edition) The Free Press: New York, NY Rosengard A, Laing I1 Ridley J1 Hunter S (2007) A literature review on multiple and complex needs. See: www.scotland.gov.uk/socialresearch (accessed 12 July 2007). Stevens S1 Sin J (2005) Implementing a self-management model of relapse prevention for psychosis into routine clinical practice. Journal of Psychiatric and Mental Health Nursing 12: 495-501. Tarrier N1 Barrowclough C1 Haddock G1 McGovern J (1999) The dissemination of innovative cognitivebehavioural psychosocial treatments for schizophrenia. Journal of Mental Health 8(6): 569-82. Welsh Assembly Government (2002) Adult mental health services: a National Service Framework for Wales. Welsh Assembly Government: Cardiff. Welsh Assembly Government (2005) 'Raising the Standard': the revised adult mental health National Service Framework and an Action Plan for Wales. Welsh Assembly Government: Cardiff. Zubin J1 Spring B (2004) Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology, Pg 103-26. Read More