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Cross-national mixed methods comparative case study of recovery-focused mental health care planning and coordination in acute inpatient mental health settings (COCAPP-A)
Background: Serious concerns have been identified in relation to care planning, patient involvement and consent to treatment in mental health wards, including for those patients detained under the Mental Health Act. Further evidence is needed to develop care planning interventions that embed dignity, recovery and participation for all people using inpatient mental health care.
Design: We propose to undertake a cross-national comparative study of recovery-focused mental health care planning in inpatient settings. This two-phase exploratory mixed methods study will produce theory and empirical evidence to complement that developed in our current study of community mental health services to inform a future whole systems intervention study. The study is guided by a theoretical framework emphasising the connections between different 'levels' of organisation (macro/meso/micro).
In phase 1 we study the macro-level through the comparative analysis of English and Welsh policy contexts. In phase 2 concurrent quantitative and qualitative data will be collected at 6 NHS Trust/Health Board case study sites (meso-level) and within each site, a single micro-level mental health ward will be selected to provide in-depth qualitative data related to care planning processes. Phase 1: We will extend our current meta-narrative mapping review (Wong et al 2013) of English and Welsh policies and the international literature on personalised recovery-oriented care planning and coordination in community settings to include inpatient settings. We will provide a review of evidence that is useful, rigorous and relevant for service providers and decision-makers and to inform Phase 2.
Phase 2: We are employing a concurrent transformative mixed methods approach with embedded case studies (Creswell 2009: 215). We will conduct six in-depth meso-level case study investigations across contrasting NHS Trusts in England (n=4) and Local Health Boards in Wales (n=2), selected to reflect variety in geography and population and include a mix of rural, urban and inner city settings providing routine inpatient care. A large sample of service users (total n=300), inpatient staff (n=300) and informal carers (n=150) will be surveyed about perceptions of acute mental health care and care planning, recovery oriented practices, therapeutic relationships and empowerment using validated questionnaires. Documents and interviews with managers, consultant psychiatrists, ward staff and informal carers (n=60) will also be generated relating to local contexts, policies and practices. In each site we will also select a single inpatient ward and conduct a series of case studies embedded within each organisational case study, to explore care planning in detail. We will invite a sample of service users (total n=36) to participate in in-depth interviews about care planning and structured narrative reviews of their care plans; undertake a structured review of anonymised care plans for a further sample (n=60) of consecutively discharged patients; and conduct observation of care planning processes (n= 18).
Framework method will be employed to integrate and compare textual and statistical summaries of qualitative and quantitative analyses within each case study site, informed by the theoretical framework focused on recovery and personalisation. Armed with our set of six within-case analyses we will then conduct a cross-case analysis to draw out key findings from across all sites
Participation in occupational therapy in psychiatric care
One of the most important challenges of health and medical care is to strength the role of the patient in the treatment. In psychiatric care the patient must be seen as a resource and should be given the opportunity to participate in his treatment. The overall aim of the thesis was to investigate and describe how patients in psychiatric care perceive participation, and how existing assessments support participation. Study I describes how patients in psychiatric institutional care perceived their opportunities to be active and to participate in their own treatment. The ICF (International Classification of Functioning Disability and Health) inspired the study. By means of a questionnaire, 61 patients reported their opinions of the value of received care, highlighting concepts such as activity and participation. Ten of those patients were then selected for a semi-structured interview. The study showed that patients who were treated according to compulsory care (LPT) were generally more dissatisfied with their opportunities to be active and participate in their own care than patients treated according to the law of health and medical care (HSL). Younger patients in particular were more dissatisfied. Some important factors in the environment were continuity and reception from the staff. Facilitating factors for activity and participation were agreement between patient and staff about the treatment plan, discussions about expectations, and creating conditions for engagement in activities and or responsibility. Study II investigates if there is harmony between the CPRS-S-A (Comprehensive Psychopathological Rating Scale-Self-Assessment), the OCAIRSâS (Occupational Circumstances Interview and Rating Scale) and the OSA (Occupational Self Assessment), and if they can replace each other when the occupational therapist collects information about the patient. Another aim was to investigate how occupational therapist uses the collected information in the treatment plan process. Fourteen patients with depression disorders took part in the study. The study showed that even if the symptoms of the disease were improved at the end of the treatment period the patients still had problems with occupational performance, reduced self-confidence and the structure of their day. Consequently the assessments cannot replace each other. The study emphasized the importance of using both interview and self-assessments when collecting information about the patient, since these methods complement each other in identifying the needs and goals of the treatment. Many problems were related to the patientâs social environment but this was not reflected in the treatment plan; few goals were identified in this area. In conclusion, occupational therapists should use self-assessments and interviews in order to support the patientâs participation in psychiatric care. Furthermore, it is important to use assessments for both occupational performance and medical symptoms when identifying the patientâs needs and goals of treatment since there is a discrepancy between the two areas; symptoms are reduced earlier than perceived problems in occupational performance. Regardless of what kind of law the patient is treated under, all patients have the right to participate in their own treatment. This thesis also shows that the social environment is important in enabling the participation of patients in their psychiatric care.En av de viktigaste utmaningarna inom hĂ€lso- och sjukvĂ„rden Ă€r att stĂ€rka patientens stĂ€llning i behandlingen. Inom psykiatrisk vĂ„rd sĂ„ mĂ„ste patienten ses som en resurs och ges möjlighet att vara delaktig i sin behandling. Det övergripande syftet med denna avhandling var att undersöka och beskriva hur patienter inom psykiatrisk vĂ„rd uppfattar delaktighet och hur existerande instrument stödjer delaktighet. Studie I beskriver hur patienter inom psykiatrisk slutenvĂ„rd uppfattar sina möjligheter till aktivitet och delaktighet under vĂ„rdtiden. ICF (Klassifikation av funktionstillstĂ„nd, funktionshinder och hĂ€lsa ) inspirerade studien. Genom en enkĂ€t svarade 61 patienter pĂ„ vĂ€rdet av den vĂ„rd som de erhöll, dĂ€r begrepp som aktivitet och delaktighet belystes. Tio patienter valdes sedan ut för en semistrukturerad intervju. Studien visar pĂ„ att patienter som vĂ„rdats utifrĂ„n Lagen om Psykiatrisk TvĂ„ngsvĂ„rd (LPT) var generellt mer missnöjda Ă€n de patienter som vĂ„rdats utifrĂ„n HĂ€lso- och SjukvĂ„rdslagen (HSL). Ăven yngre patienter var mer missnöjda. NĂ„gra viktiga faktorer i miljön som pĂ„verkar möjlighet till delaktighet var kontinuitet och bemötande frĂ„n personalen. UnderlĂ€ttande faktorer för aktivitet och delaktighet var att det fanns en samstĂ€mmighet mellan patient och personal i vĂ„rdplaneringen, att förvĂ€ntningar diskuterades, att förutsĂ€ttningar till engagemang i aktiviteter gavs och att patienten fick möjlighet att ta eget ansvar. Studie II undersöker om det finns harmoni mellan CPRS-S-A (Comprehensive Psychopathological Rating Scale-Self-Asessment), OCAIRS-S (Occupational Circumstances Interview and Rating Scale) och OSA (Occupational Self Assessment) och om de kan ersĂ€tta varandra nĂ€r arbetsterapeuten samlar information kring patienten. Ett annat syfte var att undersöka hur arbetsterapeuten anvĂ€nder den insamlade informationen i behandlingsplanen. Fjorton patienter med depressionssjukdom deltog i studien. Studien visar att Ă€ven om de medicinska symptomen förbĂ€ttras i slutet av behandlingen sĂ„ har patienten fortfarande problem i aktivitetsutförande, nedsatt sjĂ€lvkĂ€nsla och struktur pĂ„ dagarna. Bedömningsinstrumenten kan inte ersĂ€tta varandra. Studien betonar vikten av att anvĂ€nda bĂ„de intervju och sjĂ€lvskattning vid datainsamling kring patienten, dĂ„ de kompletterar varandra vid identifiering av behov och mĂ„l i behandlingen. MĂ„nga problem var relaterade till patientens sociala miljö, dock saknades detta i behandlingsplanerna; fĂ„ mĂ„l och Ă„tgĂ€rder identifierades inom detta omrĂ„de. Sammanfattningsvis, arbetsterapeuten bör anvĂ€nda sjĂ€lvskattningar och intervjuer i syfte att stödja delaktighet inom psykiatrisk vĂ„rd. Dessutom Ă€r det betydelsefullt att anvĂ€nda bedömningsinstrument bĂ„de för aktivitetsutförande och medicinska symptom för att identifiera patientens behov och mĂ„l i behandlingen dĂ„ det Ă€r en diskrepans mellan dessa tvĂ„ omrĂ„den; medicinska symptomen reduceras tidigare Ă€n upplevda problem i aktivitetsutförandet. Oavsett vilken lag som styr vĂ„rdformen sĂ„ har alla patienter rĂ€tt till delaktighet i sin egen behandling. Denna avhandling visar ocksĂ„ pĂ„ att den sociala miljön Ă€r viktigt för delaktighet för patienter inom psykiatrisk vĂ„rd
An Empirical Research About Leasing
Idag anvÀnds leasing som ett alternativt finansieringssÀtt vid anskaffning av olika tillgÄngar och innebÀr lÄngtidsuthyrning. Till exempel kan leasing vara ett alternativ till avbetalningsköp eller lÄn. Ett leasingavtal kan antingen vara operationellt eller finansiellt. Ett operationellt leasingavtal kan liknas vid en vanlig hyressituation medan ett finansiellt leasingavtal i sin renaste form kan liknas vid ett avbetalningsköp. För att bestÀmma vilken form av leasing som Àr aktuell undersöks hur de ekonomiska fördelarna och riskerna Àr fördelade mellan leasegivaren och leasetagaren. Leasing styrs och utvecklas till stor del av marknadens aktörer och av Skatteverkets bedömningar eftersom det i dagslÀget saknas en uttrycklig lagstiftning om leasing. I denna uppsats, som till stor del bygger pÄ information som inhÀmtats via empiriska undersökningar, presenteras de olika leasingformerna samt vilken normgivning som finns. Vidare presenteras praktikernas syn pÄ följande frÄgestÀllningar rörande leasing: 1) Vilka frÄgor Àr vanligaste vid leasing? 2) Vilka upplÀgg/transaktioner som ges/avrÄds ifrÄn? 3) Skatteverkets hantering av leasing 4) Samordning av leasingavtalens parter 5)Varför vÀljer företag leasing som finansieringsform? 6) FörÀndrade flygplansleasingmÄlen tidigare praxis? 7) Finns behov av en lagreglering? Uppsatsen avslutas med mina egna reflektioner pÄ frÄgestÀllningarna
An Empirical Research About Leasing
Idag anvÀnds leasing som ett alternativt finansieringssÀtt vid anskaffning av olika tillgÄngar och innebÀr lÄngtidsuthyrning. Till exempel kan leasing vara ett alternativ till avbetalningsköp eller lÄn. Ett leasingavtal kan antingen vara operationellt eller finansiellt. Ett operationellt leasingavtal kan liknas vid en vanlig hyressituation medan ett finansiellt leasingavtal i sin renaste form kan liknas vid ett avbetalningsköp. För att bestÀmma vilken form av leasing som Àr aktuell undersöks hur de ekonomiska fördelarna och riskerna Àr fördelade mellan leasegivaren och leasetagaren. Leasing styrs och utvecklas till stor del av marknadens aktörer och av Skatteverkets bedömningar eftersom det i dagslÀget saknas en uttrycklig lagstiftning om leasing. I denna uppsats, som till stor del bygger pÄ information som inhÀmtats via empiriska undersökningar, presenteras de olika leasingformerna samt vilken normgivning som finns. Vidare presenteras praktikernas syn pÄ följande frÄgestÀllningar rörande leasing: 1) Vilka frÄgor Àr vanligaste vid leasing? 2) Vilka upplÀgg/transaktioner som ges/avrÄds ifrÄn? 3) Skatteverkets hantering av leasing 4) Samordning av leasingavtalens parter 5)Varför vÀljer företag leasing som finansieringsform? 6) FörÀndrade flygplansleasingmÄlen tidigare praxis? 7) Finns behov av en lagreglering? Uppsatsen avslutas med mina egna reflektioner pÄ frÄgestÀllningarna
Occupational Performance and Affective Symptoms for Patients with Depression Disorder
The aim of this study was to describe recovering over time in occupational performance and in affective symptoms for patients with depression disorder by using different assessments and methods for collecting data. A longitudinal design with data collections on repeated occasions was used. The Occupational Circumstances Assessment Interview and Rating Scale and Occupational Self-Assessment were used for measuring occupational performance, and for affective symptoms, a Comprehensive Psychopathological Rating Scale Self-Assessment was used. Fourteen patients with depression disorder were included in the study. The result indicates that affective symptoms improve earlier than occupational performance. Furthermore, self-assessment seems to reflect more improvement to the patient than interview-based assessment. Different kinds of assessment and different kinds of data collection methods seem to facilitate the understanding of the patients recovering. In addition habituation was the most important item for the patients to manage. One implication for practice is that patients may need an extended period of treatment supporting occupational performance