Voluntary and involuntary hospitalizations in acute psychiatric wards in Norway

ENGLISH ABSTRACT Background and aim The use of coercion in mental health care services has been widely debated, and it is agreed that the level of coercive hospitalizations should be as low as possible. In 2004-2005, SINTEF Health was commissioned by the Norwegian Directorate of Health and Social Affairs to build up, establish and lead an Evaluation Network for Acute Psychiatry. SINTEF Health invited all local health trusts in Norway to participate. The purpose was for the local health trusts in Norway to come together and establish new knowledge about acute psychiatry - an area that so far had too little focus with regard to quality assurance and research in Norway. Thus, the Multi-Center Study for Acute Psychiatry (MAP) was established. This dissertation takes a closer look at the use of involuntary hospitalizations and the factors that influence this process. Study One: - Predictors of involuntary hospitalizations to acute psychiatry Rates of involuntary hospitalized (IH) patients and involuntary psychiatric treatment of people with mental illness reflect characteristics of national mental health care and laws or other legal frameworks. International studies on the rates of IH in psychiatric hospitals show great variability in results. It is, however, very difficult to compare figures due to differences in methodology of studies and legislation between countries. The aims of Study One were to examine to (i) the rates of patients admitted to 20 acute psychiatric ward units in Norway for IH, (ii) compare voluntary hospitalized (VH) with IH patients’ and (iii) describe the predictors of IH. Study Two: - Voluntary and involuntary acute psychiatric hospitalization in Norway: A 24h follow up study The Norwegian Mental Health Care Act states that patients who are involuntarily admitted to a hospital must be reassessed by a psychiatrist or a specialist in clinical psychology within 24 hours to assess whether the patient fulfils the legal criteria of the psychiatric status and symptoms. International research on the process of reassessment of IH in psychiatry is scarce, and an investigation of Norway's routine re-evaluation of IH patients may increase knowledge and understanding of this aspect of psychiatric treatment. The aims of Study Two were to (i) investigate the rate of conversion from IH to a VH status; and (ii) identify the predictors of conversion from IH to VH. Study Three: - Patients’ attitudes to psychiatric hospitalization: A national multicentre study in Norway. Being IH raises a number of issues: attitudes from family and society, stigma of being hospitalized against patients own will, and the conflict of autonomy versus need for treatment. Law/policymakers, governments and the public want a reduction in IH. The aims of Study Three were to (i) investigate to what degree do patients referred for VH and IH state that they want admission or not; and (ii) what are the predicting factors for IH patients who stated they wanted admission. Methods The Multi-centre study of Acute Psychiatry (MAP) included all cases of acute consecutive psychiatric admissions in 20 acute psychiatric units in Norway, representing about 75% of the Norwegian acute psychiatric units during 2005–2006. Data included an Admission registration form describing admission variables and the rating scales of Global Assessment of Functioning and Health of the Nation Outcome Scales. Of the full sample of 3.326 referred patients for admission, 3.051 patients provided data on wanting admission or not. We studied demographics and characteristics of the two groups (VH and IH). We then did a logistic regression analysis by using generalized linear mixed modelling based on data from 1.231 IH patients to calculate predictors of IH who wanted admission. Results Study One: Fifty-six percent of the sample were VH and 44% were IH. Regression analysis identified contact with police, referred by physicians who did not know the patient, contact with health services within the last 48 hours, not living in own apartment or house, high scores for aggression, level of hallucinations and delusions, and contact with an out-of office hours / emergency primary health care clinic within the last 48 hours and low GAF symptom score as predictors for IH. IH patients were older, more often male, non-Norwegian, unmarried and had a lower level of education. They were more likely to have a disability pension or received social benefits, and were more often admitted during evenings and nights, found to have more frequent substance abuse, less often responsible for children and were less frequently motivated for admission. IH patients had less contact with psychiatric services before admission. Most patients were referred because of a deterioration of their psychiatric illness. Study Two: Out of 1468, admissions who were IH (44%), 1148 (78.2%) remained on IH status, while 320 patients (21.8%) were converted to VH. The predictors of conversion from IH to VH (IH → VH) after re evaluation of a specialist included patients wanting admission, better scores on Global Assessment of Symptom scale (GAF), fewer hallucinations and delusions and higher alcohol intake. Study Three: 69.5% of the patients stated they wanted admission. As expected, 96.5% of the VH stated they wanted admission. However, nearly one-third (29.7%) of IH patients also expressed a need for hospitalization. In a multivariate analysis, we found that being IH and wanting admission were predicted by not being transported by police, having less aggression and using less drugs. Conclusions IH seems to be guided by the severity of psychiatric symptoms and characteristics of the referred patient such as male gender, substance abuse, contact with GP or not, aggressive behaviour, low level of social functioning and lack of motivation. There was a need for assistance by the police in a significant number of cases. This complexity challenges the organization of primary health care and psychiatric health services and highlights a need to consider better pathways to care. The 24-hour re – assessment period for patients referred for IH, as stipulated by the Norwegian Mental Health Care Act, appeared to give adequate opportunity to reduce unnecessary IH, while safeguarding the patient's right to VH. It is important to explore the attitude of a patient who has been referred to involuntary hospitalization. This can form the basis for a future dialogue about alternative ways of dealing with the patient's serious mental condition, and as far as possible preserve the patient's autonomy and co-determination, and if possible reduce unnecessary involuntary hospitalizations.Some patients who expressed the need for admission are still being admitted to acute psychiatric units under IH rather than VH. Thus, it is imperative that more effort should be made in the process of referral and admission by communication with patients in order to achieve a VH. By allowing more time for the referral and admission process, the referring physician may gain more knowledge of the patient such that an IH would not be necessary. It is not within the study to establish causality concerning wrongful involuntary admission, but it is important to focus on the patient’s wishes in such complicated hospitalization processes. It is conceivable that coercion is used too much in some places. However, at the same time patients may need to receive treatment in a psychiatric hospital when this is necessary despite not being in agreement with the referral physician. Coercion should only be used based on Mental Health Care Act criteria and when it is strictly necessary for the treatment.NORWEGIAN ABSTRACT Bakgrunn og mål Bruken av tvang i psykisk helseverntjeneste er omdiskutert, og det er enighet om at nivået av tvangsinnleggelser skal være så lavt som mulig. I 2004 - 2005 fikk SINTEF Helse i oppdrag fra Sosial- og helsedirektoratet å bygge opp, etablere og lede et Evalueringsnettverk for akuttpsykiatri. SINTEF Helse inviterte alle helseforetak i landet til å delta. Hensikten var at helseforetakene kom sammen og etablerte ny kunnskap om akuttpsykiatri – et område som så langt hadde et for lite fokus med hensyn til kvalitetssikring og forskning i Norge. Dermed ble Multi - senter studiet for Akutt Psykiatri (MAP) etablert. Denne avhandlingen ser nærmere på bruken av tvangsinnleggelser og hvilke faktorer som påvirker dette

Do interprofessional teams matter? : A survey-based study of patients and team members in hospitals and rehabilitation centres in secondary health care in Western Norway.

Background Health care today is becoming more complex, and patients must interact with an array of health care professionals working within and between various health care settings. Coordinated health services meeting the patients’ needs are certainly a major challenge for the modern society. Health care professionals working in interprofessional teams is a prioritised structure and are employed to ensure coordinated, collaborative care trajectories meeting the patients’ needs in hospitals and rehabilitation centres within secondary health care. Therefore, the overall aim of this thesis is to investigate specific team functions in interprofessional teams in hospitals and rehabilitation centres, as well as to examine how these team functions are associated with continuity of care, rehabilitation benefit, and changes in health and functioning, as reported by the patients. Materials and methods The first part of the thesis (Paper I) is based on data from a cross-sectional multi-centre study investigating the quality of communication and supportive relationships in teams working in various hospitals in secondary health care. In Paper I, these qualities in teams are explored by means of a Norwegian version of the Relational Coordination Survey (RCS) with data from 263 health care professionals working in 23 care processes. RCS data were collected in 2012 and 2013. The second part of this thesis (Papers II and III) utilises data from a longitudinal cohort study investigating associations between team functions in interprofessional rehabilitation teams and patient-reported outcomes in somatic rehabilitation centres. This section of the thesis also investigates associations between patient experienced interprofessional team functions, measured by Nijmegen Continuity Questionnaire-Norwegian version (NCQ-N), and changes in patient-reported health and functioning. RCS data were collected from 94 health care professionals working in 15 interprofessional teams in somatic rehabilitation centres in Western Norway in the first half of 2016 (Papers II and III). Patients were invited to participate when they were accepted for a rehabilitation stay at a somatic rehabilitation centre. Baseline data for the 701 included patients were collected during the first half of 2015, while follow-up data were collected one year after data collection at baseline. In the first section of this thesis, linear mixed-effect models and one-way analyses of variance were employed in the statistical analyses. In the second part of this thesis, linear models were utilised to assess associations between independent (RCS, Papers II and III and NCQ-N, Paper III) and dependent variables (the patient-reported outcomes). Results A main finding of this present study was that written clinical procedures describing the care process were associated with increased quality of communication in teams (Paper I). Another main finding was the positive association between interprofessional teams scoring high RCS supportive relationship scores and patient-reported team continuity (Paper II). Furthermore, high patients reported team, personal and cross-boundary continuity was associated with improved health for the patients (Paper III). The RCS subscale scores were significantly higher among health professionals holding similar occupational roles within the team, compared to communication and relationships between other members of the team (Paper I). However, the RCS quality of communication and supportive relationships in teams did not show significant associations with changes in patient-reported health and functioning (Paper III). Conclusions and implications Working in interprofessional teams with common strategies towards reaching the patients’ goals is the preferred way of delivering health care in hospitals and rehabilitation centres in secondary health care. This present study found that the quality of communication in interprofessional rehabilitation teams was associated with improved patient-reported team continuity, reflecting the current practice of interprofessional teamwork. In addition, this present study found that patients experiencing team continuity, personal and cross-boundary continuity in the rehabilitation process reported more improvement in their health state one year after rehabilitation. On the other hand, the quality of communication and relationships in teams as reported by professionals were not associated with improvements in patient-reported health and functioning. This finding could indicate that patient-reported measures of team continuity is a better predictor for the content of teamwork most important for positive rehabilitation outcomes compared to RCS subscales. Health care professionals having similar occupational roles had better communication and relationships with other professionals holding similar occupational roles. This finding could indicate that poor understanding of other team members’ roles that consequently hinders the quality of communication and relationships. Written clinical procedures were positively associated with increased quality of communication in teams. This finding indicates that written clinical procedures might increase the quality of health care delivery, improve continuity of care and be facilitated through the implementation of evidence-based clinical pathways

Validation of GC-Orbitrap for FAME, FAEE og FAPE analysis

Etter at det i mange år har vært forsket på lipider ved bruk av GC-FID, GC-MS med sektorinstrument og med kvadrupol har det nå på laboratoriet vårt blitt byttet inn en GC-MS med orbitrap. I sammenheng med dette er målet med denne oppgaven å bli kjent med instrumentet, parameterne og hvilken betydning de har ved analyse av fettsyre metylestere (FAME). I tillegg er det sett videre på fettsyre etylestere (FAEE) og fettsyre propylestere (FAPE) i forhold til FAME. I denne oppgaven er det benyttet en Exactive GC med Orbitrap til å analysere FAME, FAEE og FAPE. For å lage FAME prøven ble det brukt en mix med 37 ulike FAME. Prøven ble analysert for å finne LOD, LOQ og RRF på de ulike FAME. For de andre alkylesterne ble det benyttet en prøve med 15 fettsyrer, som ble omestret til FAEE og FAPE. Deretter ble de også fortynnet til tre ulike konsentrasjoner for å finne LOD, LOQ og RRF. Det ble også justert på elektronenergien i fra 30-70 eV. Spenningen i C-fellen ble også justert fra 0-2,5 V. Det ble også justert på masseoppløsningen på 15 000, 30 000 og 60 000. Det ble også sett på SIM-analyse ettersom dette i teorien skal gi bedre sensitivitet, men under arbeidet ble det oppdaget at det ikke er en fordel for FAME analyse på GC-MS med orbitrap. Det er derfor ikke lagt mye tid i disse analysene og resultatene. Det ble konkludert med at instrumentet burde analyseres på en masseoppløsning på 60 000 med en c-felle spenning på 1,5 V, men kan også analyseres på 2 V ved lange karbonkjeder. I tillegg ble det konkludert med at elektron spenningen burde være på 70 eV for FAME, men det kan også være bedre å kjøre 40 eV på lengre karbonkjeder. Det ble funnet LOD for FAME til å være mellom 0,03 g/mL og 0,87 g/mL, og LOQ ble funnet til å være mellom 0,11 g/mL og 1,93 g/mL. Videre for FAEE ble det funnet LOD til å være mellom 0,06 g/mL og 0,64 g/mL og for LOQ mellom 0,21 g/mL og 2,15 g/mL. Til slutt ble LOD for FAPE funnet til å være mellom 0,05 g/mL og 0,24 g/mL og LOQ ble funnet til å være mellom 0,18 g/mL og 1,49 g/mL. Fettsyre alkylesterene er ikke så sammenlignbare ettersom FAME ble kjøpt som ferdig standard, mens FAEE og FAPE ble estrifisert på laboratoriet og vil ikke ha like nøyaktig konsentrasjon. Ut ifra resultatene som ble sett på er alle alkylesterene like i økning og minskning mellom alle de ulike fettsyrene for de korteste karbonkjedene. Beregningene av RRF viste at det er ikke like bra resultater for alle FAME på GC med orbitrap som det er på en GC-FID.After many years of research on lipids using GC-FID, GC-MS with sector instruments and with quadrupole, a GC-MS with orbitrap has now been replaced in our laboratory. Because of this, the aim of this thesis is to become familiar with the instrument, the parameters and what significance they have in the analysis of fatty acid methyl esters (FAME). In addition, fatty acid ethyl esters (FAEE) and fatty acid propyl esters (FAPE) have been considered in relation to FAME. In this thesis, an Exactive GC with Orbitrap GC-MS has been used to analyze FAME, FAEE and FAPE. To make the FAME sample, a mix of 37 different FAMEs was used. The sample was analyzed to find LOD, LOQ and RRF on the various FAME. For the other alkyl esters, a sample of 15 fatty acids was used, which was esterified to FAEE and FAPE. Then they were also diluted to three different concentrations to find LOD, LOQ and RRF. The electron energy was also adjusted from 30-70 eV. The voltage in the C-trap was also adjusted from 0-2.5 V. Mass resolution was adjusted on the mass resolution of 15 000, 30 000 and 60 000. SIM analysis was also considered as in theory it gives better sensitivity, but during the work it was discovered that there is no advantage for FAME analysis on GC-MS with orbitrap. Therefore, not much time has been put into these analyzes and results. It was concluded that the instrument should be analyzed at a mass resolution of 60,000, a ctrap voltage of 1.5 V, but can also be analyzed at 2 V for long carbon chains. In addition, it was concluded that the electron voltage should be 70 eV for FAME, but it may also be better to run 40 eV on longer carbon chains. The LOD for FAME was found to be between 0.03 µg/mL and 0.87 µg/mL, and the LOQ was found to be between 0.11 µg/mL and 1.93 µg/mL. Furthermore, for FAEE, LOD was found to be between 0.06 µg/mL and 0.64 µg/mL and for LOQ between 0.21 µg/mL and 2.15 µg/mL. Finally, the LOD of FAPE was found to be between 0.05 µg/mL and 0.24 µg/mL and the LOQ was found to be between 0.18 µg/mL and 1.49 µg/mL. The fatty acid alkyl esters are not so comparable as FAME was purchased as a finished standard, while FAEE and FAPE were esterified in the laboratory and will not have the same exact concentration. Based on the results, all the alkyl esters are equal in increase and decrease between all the different fatty acids for the shortest carbon chains. The calculations of RRF showed that there are not as good results for all FAME on GC with orbitrap as there are on a GC-FID.M-KJEM

Communication and Relational Ties in Inter-Professional Teams in Norwegian Specialized Health Care: A Multicentre Study of Relational Coordination

Introduction: The delivery of integrated care depends on the quality of communication and relationships among health-care professionals in inter-professional teams. The main aim of this study was to investigate individual and team communication and relational ties of teams in specific care processes within specialized health care. Methods: This cross-sectional multi-centre study used data from six somatic hospitals and six psychiatric units (N = 263 [response rate, 52%], 23 care processes) using a Norwegian version of the Relational Coordination Survey. We employed linear mixed-effect regression models and one-way analyses of variance. Results: The mean (standard deviation) relational coordination total score ranged from 4.5 (0.33) to 2.7 (0.50). The communication and relationship sub-scale scores were significantly higher within similar functional groups than between contrasting functional groups (P < .05). Written clinical procedures were significantly associated with higher communication scores (P < .05). The proportion of women in a team was associated with higher communication and relationship scores (P < .05). Conclusion: The Relational Coordination Survey shows a marked variation in team functions within inter-professional teams in specialized health-care settings. Further research is needed to determine the reasons for these variations.publishedVersio

Kvinners erfaringer med abortbehandling

Bakgrunn Hvert år blir det utført ca. 10 000 selvbestemte aborter i Norge, og spontanabort rammer ca. 10-30 prosent av alle svangerskap. En abort, uavhengig av type, kan være en stor psykisk belastning for en kvinne. Sykepleiere deltar i behandlingen av disse pasientene og har en viktig rolle i ivaretakelsen av denne pasientgruppen. Hensikt Hensikten med denne oppgaven er å belyse kvinners erfaringer med helsepersonell i forbindelse med en abort. Metode Denne oppgaven er en kvalitativ litteraturoversikt. Fem vitenskapelige kvalitative artikler ble valgt ut etter litteratursøk ved hjelp av PICo-skjema. Artiklene ble analysert med Fribergs metode, der to hovedkategorier og tre underkategorier ble dannet for å kategorisere resultatene. For å forstå resultatene ble sykepleieteori av Kari Martinsen og Joyce Travelbee anvendt, i tillegg til annen relevant litteratur. Resultater Studiene viser at kvinner stort sett har negative erfaringer når det kommer til behandlingen de fikk av helsepersonell. Kvinner rapporterte om manglende omsorg, der de opplevde at helsepersonell brukte upassende språk og viste lite empati under behandlingen. Mange kvinner opplevde at informasjonen de fikk var underdrevet. I tillegg til dette var det flere kvinner som savnet psykisk oppfølging. Nøkkelord: Abort, ivaretakelse, sykepleie, behandling, omsorg, informasjo

Long-Term Change and Predictors of Change in Physical and Mental Function after Rehabilitation: A Multi-Centre Study

Objective: To investigate changes and predictors of change in physical and mental function over a 3-year period after rehabilitation. Design: Prospective cohort. Participants: Patients, across diseases, living in western Norway, accepted for somatic specialized interprofessional rehabilitation (n = 984). Methods: Physical and mental function were assessed at admittance (baseline), and after 1 and 3 years using the Medical Outcome Study Short Form 36 (SF-36). Associations between changes in SF-36 component summary scores and sense of coherence, pain, disease group (musculoskeletal, neoplasm, cardiovascular, neurological, other), exercise habits and demographic variables were analysed using linear mixed modelling. Results: In the total group, mean (standard deviation) physical component summary scores improved by 2.9 (8.4) and 3.4 (9.3) points at 1 and 3 years, respectively. Mental component summary scores improved by 2.1 (9.7) and 1.6 (10.8) points. Improvement in physical component summary was significantly greater for patients with higher sense of coherence (b = 0.09, p = 0.001) and for the neoplasm disease group (b = 2.13, p = 0.046). Improvement in mental component summary was significantly greater for patients with low sense of coherence (b = –0.13, p = < 0.001) and higher level of education (b = 3.02, p = 0.0302). Interaction with age (physical component summary: b = 0.22, p = 0.039/mental component summary b = 0.51, p = 0.006) indicated larger effect at 1 year than at 3 years. Conclusion: Physical and mental function improved in the total study group over the 3-year period. Sense of coherence at baseline was associated with improved physical and mental function, suggesting that coping resources are important in rehabilitation.publishedVersio

Sulfide melts and long-term low seismic wavespeeds in lithospheric and asthenospheric mantle

Some studies of lithospheric and asthenospheric seismic structure, report mantle velocities as low as ∼4% below the reference models used. While these low wavespeeds may be attributed to thermal effects in tectonically young or actively volcanic regions, in older, tectonically stable regions low velocity anomalies apparently persist even past the decay time of any thermal perturbation, rendering such a mechanism implausible. Low volume melts can also reduce wavespeeds, but their buoyancy should drain them upward away from source regions, preventing significant accumulation if they are able to segregate. Sulfide, ubiquitous as inclusions in lithospheric mantle xenoliths, forms dense, non-segregating melts at temperatures and volatile fugacities characteristic of even old lithospheric mantle. We show that 1–5 volume percent sulfide melts can act to permanently create reductions up to 5.5% in seismic wavespeeds in areas of the lithosphere and the asthenosphere disturbed by prior melting events that carry and concentrate sulfide

Mechanisms and Geochemical Models of Core Formation

The formation of the Earth's core is a consequence of planetary accretion and processes in the Earth's interior. The mechanical process of planetary differentiation is likely to occur in large, if not global, magma oceans created by the collisions of planetary embryos. Metal-silicate segregation in magma oceans occurs rapidly and efficiently unlike grain scale percolation according to laboratory experiments and calculations. Geochemical models of the core formation process as planetary accretion proceeds are becoming increasingly realistic. Single stage and continuous core formation models have evolved into multi-stage models that are couple to the output of dynamical models of the giant impact phase of planet formation. The models that are most successful in matching the chemical composition of the Earth's mantle, based on experimentally-derived element partition coefficients, show that the temperature and pressure of metal-silicate equilibration must increase as a function of time and mass accreted and so must the oxygen fugacity of the equilibrating material. The latter can occur if silicon partitions into the core and through the late delivery of oxidized material. Coupled dynamical accretion and multi-stage core formation models predict the evolving mantle and core compositions of all the terrestrial planets simultaneously and also place strong constraints on the bulk compositions and oxidation states of primitive bodies in the protoplanetary disk.Comment: Accepted in Fischer, R., Terasaki, H. (eds), Deep Earth: Physics and Chemistry of the Lower Mantle and Core, AGU Monograp