An exploratory study of the role of trust in medication management within mental health services

Objective - To develop understandings of the nature and influence of trust in the safe management of medication within mental health services. Setting - Mental health services in the UK. Method - Qualitative methods were applied through focus groups across three different categories of service user—older adult, adults living in the community and forensic services. An inductive thematic analysis was carried out, using the method of constant comparison derived from grounded theory. Main Outcome - Measure Participants’ views on the key factors influencing trust and the role of trust in safe medication management. Results - The salient factors impacting trust were: the therapeutic relationship; uncertainty and vulnerability; and social control. Users of mental health services may be particularly vulnerable to adverse events and these can damage trust. Conclusion - Safe management of medication is facilitated by trust. However, this trust may be difficult to develop and maintain, exposing service users to adverse events and worsening adherence. Practice and policy should be oriented towards developing trust.

Development and psychometric evaluation of a new team effectiveness scale for all types of community adult mental health teams:a mixed-methods approach

Defining 'effectiveness' in the context of community mental health teams (CMHTs) has become increasingly difficult under the current pattern of provision required in National Health Service mental health services in England. The aim of this study was to establish the characteristics of multi-professional team working effectiveness in adult CMHTs to develop a new measure of CMHT effectiveness. The study was conducted between May and November 2010 and comprised two stages. Stage 1 used a formative evaluative approach based on the Productivity Measurement and Enhancement System to develop the scale with multiple stakeholder groups over a series of qualitative workshops held in various locations across England. Stage 2 analysed responses from a cross-sectional survey of 1500 members in 135 CMHTs from 11 Mental Health Trusts in England to determine the scale's psychometric properties. Based on an analysis of its structural validity and reliability, the resultant 20-item scale demonstrated good psychometric properties and captured one overall latent factor of CMHT effectiveness comprising seven dimensions: improved service user well-being, creative problem-solving, continuous care, inter-team working, respect between professionals, engagement with carers and therapeutic relationships with service users. The scale will be of significant value to CMHTs and healthcare commissioners both nationally and internationally for monitoring, evaluating and improving team functioning in practice.

Medication reconciliation by a pharmacy technician in a mental health assessment unit

Background: Medication discrepancies are common when patients cross organisational boundaries. However, little is known about the frequency of discrepancies within mental health and the efficacy of interventions to reduce discrepancies. Objective: To evaluate the impact of a pharmacy-led reconciliation service on medication discrepancies on admissions to a secondary care mental health trust. Setting: In-patient mental health services. Methods: Prospective evaluation of pharmacy technician led medication reconciliation for admissions to a UK Mental Health NHS Trust. From March to June 2012 information on any unintentional discrepancies (dose, frequency and name of medication); patient demographics; and type and cause of the discrepancy was collected. The potential for harm was assessed based on two scenarios; the discrepancy was continued into primary care, and the discrepancy was corrected during admission. Logistic regression identified factors associated with discrepancies. Main outcome measure: Mean number of discrepancies per admission corrected by the pharmacy technician. Results Unintentional medication discrepancies occurred in 212 of 377 admissions (56.2 %). Discrepancies involving 569 medicines (mean 1.5 medicines per admission) were corrected. The most common discrepancy was omission (n = 464). Severity was assessed for 114 discrepancies. If the discrepancy was corrected within 16 days the potential harm was minor in 71 (62.3 %) cases and moderate in 43 (37.7 %) cases whereas if the discrepancy was not corrected the potential harm was minor in 27 (23.7 %) cases and moderate in 87 (76.3 %) cases. Discrepancies were associated with both age and number of medications; the stronger association was age. Conclusions: Medication discrepancies are common within mental health services with potentially significant consequences for patients. Trained pharmacy technicians are able to reduce the frequency of discrepancies, improving safety. © 2013 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie.

Culture and the psychological impacts of natural disasters: Implications for disaster management and disaster mental health

In recent decades, natural disasters have caused extensive losses and damages to human psychological wellbeing, economy, and society. It has been argued that cultural factors such as social values, traditions, and attachment to a location influence communities facing and responding to natural disasters. However, the issue of culture in disaster mental health seems to have received limited attention in policy and practice. This review highlights the importance of cultural background in the assessment of vulnerability to the psychological impacts of disasters, disaster preparedness, and provision of disaster mental health services. In particular, this paper suggests the importance of cultural competence in the planning and delivery of effective disaster mental health services. In order to address the varying circumstances of people with different cultural backgrounds, disaster mental health services must be developed in a culturally sensitive manner. Development of culturally competent disaster mental health services requires significant changes in policy making, administration, and direct service provision

A study of outcomes measures in forensic mental health

Outcomes measures, which is the measurement of effectiveness of interventions and services has been propelled onto the health service agenda since the introduction of the internal market in the 1990s. It arose as a result of the escalating cost of inpatient care, the need to identify what interventions work and in what situations, and the desire for effective information by service users enabled by the consumerist agenda introduced by Working for Patients white paper. The research reported in this thesis is an assessment of the readiness of the forensic mental health service to measure outcomes of interventions. The research examines the type, prevalence and scope of use of outcomes measures, and further seeks a consensus of views of key stakeholders on the priority areas for future development. It discusses the theoretical basis for defining health and advocates the argument that the present focus on measuring effectiveness of care is misdirected without the input of users, particularly patients in their care, drawing together the views of the many stakeholders who have an interest in the provision of care in the service. The research further draws on the theory of structuration to demonstrate the degree to which a duality of action, which is necessary for the development, and use of outcomes measures is in place within the service. Consequently, it highlights some of the hurdles that need to be surmounted before effective measurement of health gain can be developed in the field of study. It concludes by advancing the view that outcomes research can enable practitioners to better understand the relationship between the illness of the patient and the efficacy of treatment. This understanding it is argued would contribute to improving dialogue between the health care practitioner and the patient, and further providing the information necessary for moving away from untested assumptions, which are numerous in the field about the superiority of one treatment approach over another.

Knowledge engineering for mental-health risk assessment and decision support

Mental-health risk assessment practice in the UK is mainly paper-based, with little standardisation in the tools that are used across the Services. The tools that are available tend to rely on minimal sets of items and unsophisticated scoring methods to identify at-risk individuals. This means the reasoning by which an outcome has been determined remains uncertain. Consequently, there is little provision for: including the patient as an active party in the assessment process, identifying underlying causes of risk, and eecting shared decision-making. This thesis develops a tool-chain for the formulation and deployment of a computerised clinical decision support system for mental-health risk assessment. The resultant tool, GRiST, will be based on consensual domain expert knowledge that will be validated as part of the research, and will incorporate a proven psychological model of classication for risk computation. GRiST will have an ambitious remit of being a platform that can be used over the Internet, by both the clinician and the layperson, in multiple settings, and in the assessment of patients with varying demographics. Flexibility will therefore be a guiding principle in the development of the platform, to the extent that GRiST will present an assessment environment that is tailored to the circumstances in which it nds itself. XML and XSLT will be the key technologies that help deliver this exibility.

Medication error in mental health:implications for primary care

Medication errors are associated with significant morbidity and people with mental health problems may be particularly susceptible to medication errors due to various factors. Primary care has a key role in improving medication safety in this vulnerable population. The complexity of services, involving primary and secondary care and social services, and potential training issues may increase error rates, with physical medicines representing a particular risk. Service users may be cognitively impaired and fail to identify an error placing additional responsibilities on clinicians. The potential role of carers in error prevention and medication safety requires further elaboration. A potential lack of trust between service users and clinicians may impair honest communication about medication issues leading to errors. There is a need for detailed research within this field.

Development of a probabilistic graphical structure from a model of mental health clinical expertise

This thesis explores the process of developing a principled approach for translating a model of mental-health risk expertise into a probabilistic graphical structure. Probabilistic graphical structures can be a combination of graph and probability theory that provide numerous advantages when it comes to the representation of domains involving uncertainty, domains such as the mental health domain. In this thesis the advantages that probabilistic graphical structures offer in representing such domains is built on. The Galatean Risk Screening Tool (GRiST) is a psychological model for mental health risk assessment based on fuzzy sets. In this thesis the knowledge encapsulated in the psychological model was used to develop the structure of the probability graph by exploiting the semantics of the clinical expertise. This thesis describes how a chain graph can be developed from the psychological model to provide a probabilistic evaluation of risk that complements the one generated by GRiST’s clinical expertise by the decomposing of the GRiST knowledge structure in component parts, which were in turned mapped into equivalent probabilistic graphical structures such as Bayesian Belief Nets and Markov Random Fields to produce a composite chain graph that provides a probabilistic classification of risk expertise to complement the expert clinical judgements

Belief nets for mental health

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Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRiST

Aim: To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care. Background: Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services. Methods: Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis. Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems. Conclusions: A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.

Understanding data collection behaviour of mental health practitioners

Failure to detect patients at risk of attempting suicide can result in tragic consequences. Identifying risks earlier and more accurately helps prevent serious incidents occurring and is the objective of the GRiST clinical decision support system (CDSS). One of the problems it faces is high variability in the type and quantity of data submitted for patients, who are assessed in multiple contexts along the care pathway. Although GRiST identifies up to 138 patient cues to collect, only about half of them are relevant for any one patient and their roles may not be for risk evaluation but more for risk management. This paper explores the data collection behaviour of clinicians using GRiST to see whether it can elucidate which variables are important for risk evaluations and when. The GRiST CDSS is based on a cognitive model of human expertise manifested by a sophisticated hierarchical knowledge structure or tree. This structure is used by the GRiST interface to provide top-down controlled access to the patient data. Our research explores relationships between the answers given to these higher-level 'branch' questions to see whether they can help direct assessors to the most important data, depending on the patient profile and assessment context. The outcome is a model for dynamic data collection driven by the knowledge hierarchy. It has potential for improving other clinical decision support systems operating in domains with high dimensional data that are only partially collected and in a variety of combinations.