Example Essays - Nursing Essays
Community mental health: The effect of de-institutionalisation on clients with severe and enduring mental health problems.
De-institutionalisation refers to the shift of patients from psychiatric hospital to community based care. I will attempt to define the community nurses role in the capacity of mental health issues. It is important to define exactly what is meant by mental health problems, and the concept of an institution in order to determine the practicalities of implementation, including collaboration of all those involved in the patients care and the facilities available to clients.
Definitions:
1.Mental ill health: behavioural or psychological syndrome that causes significant distress, disability, or an increased risk of suffering. The syndrome is considered to be a manifestation of some behavioural, biological, or psychological dysfunction. (Egerton 1994)
2.Institutions: The Lunatics Act of 1845 required all counties in this country to appropriately provide care for people incarcerated in 'Madhouses', which prompted the growth of a great many public asylums - safe places where patients could obtain asylum and be protected from everyday stresses and persecution. Such places regarded their main ambition to be to cure people of their ills. Until the end of the last century, due to a large strain placed upon resources, the main intention was no longer cure but prevention of trouble (Watts & Bennett, 1983).
3.De-institutionalisation: is defined by Bachrach (1976) as the 'contraction of institutional settings with a corresponding increase in community based settings'. The policy of de-institutionalisation calls for the provision of treatment and supportive care for medically and socially dependent individuals in the community rather than an institutional setting.
With these concepts defined, it is important to discuss the different uses of community care with regards to de-institutionalisation. There are 3 major types of outpatient commitment which can be discerned: (Power,1998; Szmukler &Appelbaum, 2001)
- As a substitute for hospital admission.
- To facilitate earlier discharge from hospital (a form of 'conditional discharge').
- To prevent relapse.
De-institutionalisation has been high on the list of priorities for many primary health care trusts, and the need to implement effective protocol is beginning to be addressed within NHS re-structuring plans. Continuity of care was one of nine priority themes identified in a national listening exercise carried out in 1999 by the new National Co-ordinating centre for NHS service delivery and organisation R &D (NCCSDO) (Fulop et al, 2000)
Severe metal illnesses (SMI's) are a group of primarily psychotic disorders that are, by definition, long term and associated with impaired social functioning (Ruggieri et al 2000). Continuity of care for patients who experience SMI has assumed particular significance because of several important historical, clinical and political factors which include:
- De-institutionalisation- rather than hospitals attempting to meet health and social needs of patients, this task is now undertaken by a range of primary and secondary health and social care providers.
- The clinical features of psychosis- people with SMI may lack in-site into their condition and may be reluctant to seek help or actively avoid contact with services.
- Concerns about untoward incidents involving people with SMI- repeated official enquiries have linked incidents to failure to co-ordinate patient care.
These factors are operating in the context of specific increased emphasis on a patient orientated NHS. (Gooch, Leff 1996)
Ethical considerations:
It is important to realise that any aspect of health care for the mentally ill incorporates multiple and complicated ethical dilemmas. These broadly include: Capacity or competency, Right to refuse treatment or services, Patients knowledge of their rights, and representation at mental health review tribunals.
If the principle that patients' should be detained/treated in the environment of least restriction then, it can be argued that community detention provides for this as it allows treatment/management to be in the community as opposed to hospital (Bean and Mounser, 1994; Hambridge and Watt, 1995; Osuna and Cuena, 1995; McIvor, 1998; Power, 1999). A further argument for community detention is that there is no difference in compulsory treatment in hospital or the community, especially if it is considered that "compulsory treatment is a right to which individuals are entitled" (Turner, 1994).
Socio-political considerations:
Integration, Fair access to care services, social inclusion, accommodation, occupation, social support and leisure, health and well being of children all have to be considered when deciding on the care-plan for a client with severe and enduring mental health problems. There is concern that de-institutionalisation is simply a response to a political agenda rather than because of their clinical merit.
Outcomes of de-institutionalisation:
The de-institutionalisation of people characterised as having more complex health needs, combined with recent health service shift towards primary led care, has meant that the Primary Health Care Teams (PHCT's ) are increasingly responsible for the provision of health care to people with learning difficulties. (Kerr 1998)
Research shows that those de-institutionalised have higher levels of morbidity (Howells 1997), Lower levels of health promotion (Kerr, et al 1996), and lower rates of consultation and problems of understanding and communication. (Howells 1986; Cole 1986; Wilson & Haire 1990)
To measure outcome it is necessary to be clear for whom and why de-institutionalisation is supposed. It is generally viewed as being for someone with a serious mental illness that is at risk of deterioration if they are non-compliant with medication, and may also be seen to have a use for people who are treatment resistant but who are at additional risk, such as neglect (Power, 1999). This would then rely on the service making a commitment to provide such provisions for those at high risk in order to achieve a positive outcome.
De-institutionalisation has, generally, been introduced with no additional resources (McIvor, 1998; Power, 1999), therefore decreasing hospital admission is not the only outcome that might be important in determining its success. There is an assumption that improved compliance with medication will improve social, clinical and other outcomes, however there is little evidence for this, with one study reporting no change other than improved compliance. (Swartz et al. 1995)
Integration and collaboration of services:
Primary Health Care Trusts are the principle providers of primary clinical care to people with learning difficulties who live in the community. It is recommended that they should work closely with specialist services by developing shared care arrangements. (DoH 1998) Principles of good Primary Health Care include: Quality, Fairness, Accessibility, Responsiveness, and Efficiency of the services. (DoH 1996)
Effective care of severely mentally ill individuals requires a close working relationship between Psychiatrists, Social Workers and Community Psychiatric Nurses (CPNs). Without these three professions working together, it is simply not possible to provide safe care. All three have essential, unsubstitutable roles, their relationships having been established in the Mental Health Act 1959. This three way partnership provides assessment, treatment and the capacity to use the provisions of the Mental Health Act 1983. Over the years these three disciplines, have been welded, by community mental health teams (CMHTs) into a flexible, supportive unit addressing health and social care needs of patients simultaneously. This team structure has been a distinguishing feature of UK mental health practice for 40 years, and by the 1980s over 80% of the population had access to such a therapeutic partnership (Johnson & Thornicroft, 1993)
CPN's play a vital role in the success of de-institutionalisation. They have the ability to implement care programs on a one-to-one basis to those in the community, whilst at the same time reducing social stigma towards mental ill health, enabling clients to re-integrate into the community. The three-way team is not sufficient however to provide optimal care in the community. For this reason CMHT's have extended their membership to include clinical psychologists, occupational therapists and, in some areas, mental health support workers, vocational counsellors and more. In many such teams, the consultant psychiatrist is identified as the team leader, but this role is complex and far removed from asymmetric autocracy of the old psychiatric hospital.
Supporting the often precarious survival of vulnerable individuals has shifted the balance of modern mental health care towards longer periods of care outside hospital. This has extended the range of partnerships required and significantly altered their relative importance. Effective and close working relationships with primary care are essential, with social care becoming increasingly more important in the process of de-institutionalisation. Housing, finances, personal safety, occupation, and durable support networks are essential for a stable, dignified existence. A range of voluntary services, community and self-help groups augment the enhanced role that social services now have.
The relationship between mental health staff and patients' families (who comprise the vast majority of carers) is, arguably, the most dramatically changing partnership in provision of care for those with severe and enduring mental health problems. The move to the community has shifted a significant burden of care to families. Most family members welcome their role in looking after and supporting one another. In the first, optimistic wave of de-institutionalisation, their contribution was taken for granted and essentially ignored.
Policies:
Mental health policy in England is undergoing radical change, especially in the operations and structure of local mental health centres, which are occurring in response to policy and funding shifts at national level. Clinical and administrative staffing changes reflect both cutbacks in funding for traditional outpatient and inpatient services, as well as increases in partial care, community, residential and case management services. The most likely explanation for the change in service provision is the separate operation of different professional groups acting as gatekeepers for their own resources.(DoH 1998)
Mind, a charity focusing on mental health issues is working with organisations such as the Royal College of GPs to highlight the areas of community care which need to be improved, such as:
- people should be able to access a GP of choice
- primary care staff should have more training in mental health issues
- a range of treatment and support options should be available, including talking treatments.
- sufficient information about treatment options and services should be provided
- primary care services need to be culturally sensitive.
Mind's My Choice Campaign:
Last year, Mind campaigned to improve treatment choice in primary care, working with MPs and Primary Care trusts to promote its 'Model for Choice in Primary Care'. Local GPs and trusts worked with groups from across the country to promote good practice and highlight areas which need to be improved.
Social inclusion:
Social exclusion is what happens when, marginalised by society, people are not able play a full and equal part in their community. Many people who experience mental distress experience stigma and discrimination, and live in poverty. They may find it hard to find adequate housing or access employment. The net result is that people can become seriously isolated and excluded from social and working life.
'Following the publication of the Social Exclusion Unit's (SEU) report into mental health and social exclusion, the National Institute for Mental Health in England (NIMHE) have been charged with implementing the 27 action points listed in the SEU report. NIMHE are working on a number of policy areas including employment, education, social networks, housing and homelessness, direct payments, income and benefits.' (DoH 1998)
Nursing role in de-institutionalisation:
It is the duty of CPN's to:
- Promote wellness
- Be able to meet basic needs for health and safety
- Prevent social isolation, and emotional distress
- Identify problems, disorders and behavioural incapacity in response to normal life challenges.
Mental health considerations in community oriented nursing include: Knowledge about mental health services, populations at risk, psychiatric syndromes and illness outcomes and the effects of mental illness on families and communities.
The psychiatric-mental health nurse emphasizes health promotion and health maintenance reflecting nursings' long-standing concern for community. individual, family and group well being by conducting health assessments, targeting at-risk situations, and initiating interventions such as assertiveness training, parenting classes, stress management, and health teaching, in addition to targeting potential complications related to symptoms of mental illness and adverse treatment effects.
The nurse must be aware of any activity which places the rights or well being of the patient in jeopardy and take appropriate action in the patient's behalf, this stems from nursing's strong commitment to the health, welfare, and safety of the patient. In clinical practice, the nurse-advocate 'vigilantly protects the rights of patients and speaks for those who, for whatever reason, cannot speak for themselves' (Bean.P, Mounser.P 1994).
The nurse is often the coordinator for the community-based multidisciplinary team and is responsible for: case finding, intake screening, crisis intervention, referral, follow-up and evaluation.(DoH 1998)
Conclusion:
Although it is difficult to statistically assess the effectiveness of de-institutionalisation due to lack of un-biased data, it can be ascertained that the principle behind the idea has considerable potential. Increased provision and availability of facilities in the community coupled with the recognition for integration of a multidisciplinary team means that continuity of care outside of the hospital setting is becoming increasingly likely and effective. A rise in the number of Primary Health Care Teams that now have facilities to provide care within the community for those with severe and enduring mental health problems, can be attributed to the recognition given to the role of de-institutionalisation in promoting mental well being on a local and national level. The Department of Health (DoH) coupled with NHS trusts and the Royal College of General Practitioners are now starting to work together to be able to provide the care to clients outside of the hospital setting, enabling faster re-integration into society and ultimately recovery.
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References:
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