Common People : Physical health, lifestyle and quality of life in persons with psychosis and their striving to be like everybody else

Background: As psychosis is often a lifelong disorder, improved health-related quality of life (HRQoL) can be a relevant treatment goal. Persons with psychosis have significantly reduced physical health. Research has demonstrated a great excess of mortality due to cardiovascular diseases, as psychosis may lead to an inactive lifestyle and difficulties making healthy lifestyle choices. Metabolic side effects of second-generation antipsychotics are also common. Many are therefore affected by the metabolic syndrome. The overall situation calls for action by developing health promotion interventions suitable for this group. In recent years, there has been an increased interest in the physical health of persons with psychosis. However, efforts have not been optimally tailored to the needs of this group, and health care services have not done enough, despite being aware of the problem. Aim: The general aim of this thesis was to study HRQoL, and metabolic risk factors in persons with psychosis, and by a health promotion intervention and through the participants’ own perspective contribute to an improvement in lifestyle interventions. Methods: Study 1 had a cross-sectional cohort study design that was carried out in specialised psychiatric outpatient departments in Sweden. The patients (n=903) were diagnosed with a psychotic disorder and invited consecutively to participate. A prospective population-based study of public health in the south-east of Sweden (n=7238) served as reference group. Patients were assessed using psychiatric questionnaires, including the Global Assessment of Functioning (GAF). Health-related quality of life was assessed using the EQ5D, both for patients and the population. Several other health status outcomes relevant to the metabolic syndrome were measured, together with lifestyle habits and clinical characteristics. Study II, III and IV were based on a lifestyle intervention for persons with psychosis. Study II was a longitudinal intervention study with a matched reference sample. The purpose of the lifestyle intervention  was to promote a healthier lifestyle by combining theoretical education with physical activities. The intervention group consisted of 42 participants. A matching procedure was made in which two individuals per participant were matched (n=84) into a reference group. The reference sample was matched for sex, BMI class, and being of as similar an age as possible. Socio-demographics were collected and metabolic risk factors relevant to the metabolic syndrome were measured. Symptom severity was measured using Clinical Global Impression (CGI), and HRQoL was assessed using EQ5D. Measurements were made at baseline and at a one-year follow-up. In study III, a qualitative exploratory study was conducted in order to explore prerequisites for a healthy lifestyle. Data were collected through individual interviews (n=40), using a semi-structured interview guide with participants who had undergone the lifestyle intervention. Data were collected 6–7 months after the intervention had been completed. Conventional content analysis was used. Study IV was also based on these 40 interviews and aimed to describe how persons with psychosis perceive participation in a lifestyle intervention. A phenomenographic analysis approach was used. Results/conclusions: Persons with psychosis are at great additional risk of physical comorbidity. Almost half of the patients met the criteria for metabolic syndrome. In addition, persons with psychosis had significantly lower HRQoL in all dimensions in the EQ5D, except for the pain/discomfort dimension. The only risk factor included in the metabolic syndrome that was associated with lower HRQoL was elevated blood pressure. Raised LDL-cholesterol was also related to lower HRQoL, together with low GAF, older age, high BMI, and female gender. The intervention study demonstrated that HRQoL was significantly improved in the intervention group when comparing EQ-VAS at baseline and at the one-year follow-up. It can be concluded that our intervention was not powerful enough to influence the metabolic factors to any greater extent. The key prerequisite for a healthy lifestyle seemed to be a wish to take part in the society and a longing to live like everybody else. However, many became stuck in a constant state of planning instead of taking action towards achieving a healthy lifestyle. Support by health care professionals is therefore also a prerequisite for a healthy lifestyle. This support should target the transition from thought to action and facilitate the participants’ ability to mirror themselves against healthy people in society by introducing activities they perceive that “common people” do. The challenge for health care professionals is to find a moderate intervention level that does not underestimate or overestimate the person’s capacity. This can facilitate continued participation, and participants can thereby find new social contacts and achieve health benefits

Saving lives by asking questions : nurses experiences of suicide risk assessment in telephone counselling in primary health care

Aim: To explore nurses experiences of suicide risk assessment in telephone counselling (TC) in primary health care (PHC). Background: Globally, priority is given to developing suicide prevention work in PHC. However, suicide risk assessments in TC are not included in these interventions even though these are a common duty of nurses in PHC. More expertise in the field can contribute to knowledge important for developing nurses tasks within PHC. Methods: A qualitative interview study was conducted with 15 nurses. Data were analysed using conventional content analysis. Findings: As suicide risk assessment in TC is a common duty for nurses in PHC, they need to be listened to and given the right conditions to perform this work. The nurses lack training in how to carry out suicide risk assessments and are forced to learn through experience. Intuition guides them in their work. A prerequisite for making correct assessments over the telephone is that the nurses are given time as well as the right competence. The PHC organisation needs to create these conditions. Furthermore, interventions to support suicide prevention need to include strategies to help nurses perform suicide assessment in TC.Funding Agencies|Department of Psychiatry, Ryhov County Hospital, Jonkoping</p

Brief Admission for Patients with Self-Harm from the Perspective of Outpatient Healthcare Professionals

The aim of the study was to describe the role of brief-admission (BA) in treating high-risk patients with self-harm from the perspective of outpatient healthcare staff in Sweden. Ten outpatient healthcare professionals from three psychiatric clinics were interviewed. Data were analyzed using a conventional content analysis. The findings of this study help support the role of BA as an acute crisis management intervention, and describe how BA serves as a useful adjunct to outpatient treatment, especially for patients with complementarily psychotherapeutic interventions. The findings also suggest that implementing BA may increase treatment opportunities for outpatient staff and strengthen the concept of person-centered care.Funding Agencies|Sahlgrenska Academy, University of Gothenburg and Department of Psychiatry, Region Jonkoping County</p

Conceptualizing patient participation in psychiatry : A survey describing the voice of patients in outpatient care

Background: While increasingly discussed in somatic care, the concept of patient participation remains unsettled in psychiatric care, potentially impeding person-centred experiences. Objective: To describe outpatient psychiatric care patients conceptualization of patient participation. Design: An exploratory survey. Setting and participants: Patients in four psychiatric outpatient care units. Variables: Patients conceptualized patient participation by completing a semi-structured questionnaire, including optional attributes and free text. Data were analysed using statistics for ordinal data and content analysis for free text. Results: In total, 137 patients (69% of potential respondents) completed the questionnaire. The discrete items were favoured for conceptualizing patient participation, indicating a primary connotation that participation means being listened to, being in a reciprocal dialogue, learning about ones health care and managing ones symptoms. Additional free-text responses acknowledged the attributes previously recognized, and provided supplementary notions, including that patient participation is about mutual respect and shared trust. Discussion: What patient participation is and how it can be facilitated needs to be agreed in order to enable preference-based patient participation. Patients in outpatient psychiatric care conceptualize participation in terms of both sharing of and sharing in, including taking part in joint and solo activities, such as a reciprocal dialogue and managing symptoms by yourself. Conclusion: While being a patient in psychiatric care has been associated with a lack of voice, an increased understanding of patient participation enables person-centred care, with the benefits of collaboration, co-production and enhanced quality of care. Patient contribution: Patients provided their conceptualization of patient participation in accordance with their lived experience

Relatives' experiences of brief admission in borderline personality disorder and self‐harming behaviour

Abstract Aim The aim of this study is to describe experiences of brief admission (BA) of people with borderline personality disorder and self‐harming behaviour, from the perspective of their relatives. Design A descriptive qualitative design was chosen. Methods Twelve relatives of people with borderline personality disorder and self‐harming behaviour who had access to BA were interviewed. Data were analysed with qualitative conventional content analysis. Results One overarching category: Hope for the future and three categories occurred: Breathing space, Personal responsibility and Structure. BA created hope for the future and the relatives appreciated that BA is a freer and easily accessible form of care that enables help at an early stage, compared with usual care. When BA functions, the structure and pre‐determined days of care give relatives a breathing space, and the uncertainty diminishes for the children, as the parent can still be present during inpatient care. The lack of places was described as a disadvantage of BA

Evaluation of a healthcare walk-in centre in an immigrant-dense area from the perspective of Swedish-born patients

Aim: This study evaluates a healthcare walk-in centre in an immigrant-dense area from the perspective of Swedish-born patients. Background: The studied healthcare centre started a walk-in centre to increase healthcare accessibility for immigrants. This form of care is not primarily for Swedish-born patients although everyone is welcome. For this reason, it is important to evaluate the walk-in centre from different perspectives: the healthcare workers, the immigrant patients, and in this study focusing on the Swedish-born patients. Method: This qualitative exploratory study used content analysis to analyse data collected from semi-structured interviews. Semi-structured interviews were held with 12 purposively sampled Swedish-born patients visiting a healthcare centre in Sweden. Findings: Most informants characterised the care they received as professional and timely and noted that accessibility was the main reason they sought care at the walk-in centre. In addition, they noted that being able to seek care on the day they want creates a feeling of security. However, Swedish-born informants seemed to prefer a traditional healthcare centre, although they viewed the walk-in centre as legitimate because everyone has access to it. Conclusion: As the walk-in centre was perceived as having good accessibility, participants experienced that they could easily receive help for minor health problems. However, they also identified several ways the walk-in centre could be improved. For example, some participants preferred to remain outside while awaiting their turn to see a healthcare provider and wanted immigrant patients to leave their relatives at home when possible to minimise the risk of spreading infection. In addition, some participants thought a triage system could be implemented so that more severe cases could advance more quickly in the queue. The homogeneous sample of informants raises questions about whether this healthcare model is indeed accessible to everyone

Relatives experiences of brief admission in borderline personality disorder and self-harming behaviour

AimThe aim of this study is to describe experiences of brief admission (BA) of people with borderline personality disorder and self-harming behaviour, from the perspective of their relatives.DesignA descriptive qualitative design was chosen.MethodsTwelve relatives of people with borderline personality disorder and self-harming behaviour who had access to BA were interviewed. Data were analysed with qualitative conventional content analysis.ResultsOne overarching category: Hope for the future and three categories occurred: Breathing space, Personal responsibility and Structure. BA created hope for the future and the relatives appreciated that BA is a freer and easily accessible form of care that enables help at an early stage, compared with usual care. When BA functions, the structure and pre-determined days of care give relatives a breathing space, and the uncertainty diminishes for the children, as the parent can still be present during inpatient care. The lack of places was described as a disadvantage of BA.Funding Agencies|Psychiatric Clinic, Ryhov Region Joenkoeping; Department of Psychiatry, Ryhov County Hospital, Joenkoeping [969854]</p

Experiences of how brief admission influences daily life functioning among individuals with borderline personality disorder (BPD) and self-harming behaviour

Aims and objectives The aim of this study was to explore experiences of how brief admission influences daily life functioning among individuals with borderline personality disorder (BPD) and self-harming behaviour. Background Brief admission (BA) is a crisis nursing intervention designed to reduce long hospitalisations and the risk of suicide. The intention of the intervention is to develop autonomy and to encourage the patient to take responsibility for and control over their own care and treatment. There are studies in the area that target individuals with psychosis and bipolar disorders, but no previous studies have been found examining how BA impacts upon daily life functioning among people with BPD who self-harm. Design A descriptive qualitative design was chosen. Methods Data were collected using qualitative individual interviews with 16 patients with BPD and self-harming behaviour who had been assigned to BA. The data were analysed using conventional content analysis. The study was conducted in accordance with COREQ guidelines. Results The results show that BA was perceived as a functioning nursing intervention that promoted self-determination and self-care. This contributed to increased security in daily life. BA made it possible for individuals to maintain everyday routines, employment and relationships more easily. Conclusions Our findings suggest that BA was experienced to have a positive impact on daily life functioning. Relevance to clinical practice Brief admission enabled the balance of power to be shifted from the nurse to the patient, and provides conditions for patients to take responsibility for their mental condition and to become aware of early signs of deterioration, in line with the basic ideas of person-centred care.Funding Agencies|Department of Psychiatry, Ryhov County Hospital, Jonkoping</p

Manuscript Title: Nurses Experiences of Suicide Prevention in Primary Health Care (PHC) - A Qualitative Interview Study

Aim The purpose was to describe nurses experiences of suicide prevention work in primary health care (PHC). Background Suicide is the tenth most common cause of death among adults. PHC has an important role in suicide prevention work, as patients often had contact with PHC before their suicide rather than with specialist psychiatric care. Nurses often have the first contact with the patient and are responsible for triage and assessment, making them important in suicide prevention work. Previous studies shed light on suicide prevention in a primary care context, but the nurses voices are missing. Methods Fifteen qualitative interviews were conducted with nurses in primary health care. Data was analyzed according to conventional content analysis techniques. Findings Nurses may avoid asking questions about suicidality for fear of what to do with the answer. To support the nurses ability in suicide prevention work, both educational and practical experience are fundamental. There was a lack of clarity about who is carrying responsibility for the patient, and it turned out to be difficult to help the patient move further to the next care institution. There was a need for guidelines as well as routines for collaboration with other care actors in suicide prevention work. Conclusion The PHC organization does not support nurses in suicide prevention, therefore they need the right conditions for their work. Suicide prevention needs to be given greater focus and space within education as well as training in the ongoing clinical work, which can be performed with less extensive efforts.Funding Agencies|Futurum -Akademin for Halsa och Vard, Region Jonkoping</p