Experiences and satisfaction of children, young people and their parents with alternative mental health models to inpatient settings: a systematic review

Models of integrated care for young people experiencing medical emergencies related to mental illness: a realist systematic review

Mental illness heightens risk of medical emergencies, emergency hospitalisation, and readmissions. Innovations for integrated medical-psychiatric care within paediatric emergency settings may help adolescents with acute mental disorders to get well quicker and stay well enough to remain out of hospital. We assessed models of integrated acute care for adolescents experiencing medical emergencies related to mental illness (MHR). We conducted a systematic review by searching MEDLINE, PsychINFO, Embase, and Web of Science for quantitative studies within paediatric emergency medicine, internationally. We included populations aged 8-25 years. Our outcomes were length of hospital stay (LOS), emergency hospital admissions, and rehospitalisation. Limits were imposed on dates: 1990 to June 2021. We present a narrative synthesis. This study is registered on PROSPERO: 254,359. 1667 studies were screened, 22 met eligibility, comprising 39,346 patients. Emergency triage innovations reduced admissions between 4 and 16%, including multidisciplinary staffing and training for psychiatric assessment (F(3,42) = 4.6, P < 0.05, N = 682), and telepsychiatry consultations (aOR = 0.41, 95% CI 0.28-0.58; P < 0.001, N = 597). Psychological therapies delivered in emergency departments reduced admissions 8-40%, including psychoeducation (aOR = 0.35, 95% CI 0.17-0.71, P < 0.01, N = 212), risk-reduction counselling for suicide prevention (OR = 2.78, 95% CI 0.55-14.10, N = 348), and telephone follow-up (OR = 0.45, 95% CI 0.33-0.60, P < 0.001, N = 980). Innovations on acute wards reduced readmissions, including guided meal supervision for eating disorders (P = 0.27), therapeutic skills for anxiety disorders, and a dedicated psychiatric crisis unit (22.2 vs 8.5% (P = 0.008). Integrated pathway innovations reduced readmissions between 8 and 37% including family-based therapy (FBT) for eating disorders (X2(1,326) = 8.40, P = 0.004, N = 326), and risk-targeted telephone follow-up or outpatients for all mental disorders (29.5 vs. 5%, P = 0.03, N = 1316). Studies occurred in the USA, Canada, or Australia. Integrated care pathways to psychiatric consultations, psychological therapies, and multidisciplinary follow-up within emergency paediatric services prevented lengthy and repeat hospitalisation for MHR emergencies. Only six of 22 studies adjusted for illness severity and clinical history between before- and after-intervention cohorts and only one reported socio-demographic intervention effects.

Receiving a gift and feeling robbed: a phenomenological study on parents' experiences of Brief Admissions for teenagers who self-harm at risk for suicide

BACKGROUND

Brief Admission by self-referral is a preventive intervention here intended for individuals who recurrently self-harm and have a history of contact with emergency psychiatric services. Individuals with access to Brief Admission are empowered to self-admit to inpatient care for up to three days per stay and are encouraged to do so before experiencing crisis. Brief Admission was implemented relatively recently in child and adolescent psychiatric settings in Sweden. The purpose of this study was to phenomenologically explore the lived experience of parents whose teenagers, who recurrently self-harm and experience suicidal thoughts, use Brief Admissions.

METHODS

This is a qualitative study using phenomenological psychological analysis. We interviewed 17 parents who had experienced their teenagers using Brief Admissions. The interviews were recorded and transcribed verbatim and analyzed to arrive at the essential meaning structure of the phenomenon of Brief Admissions for the parent.

RESULTS

We identified two essential meaning structures of the parent's experience of their teenager's use of Brief Admissions: being gifted relief and hope or being robbed of everything you believed in. The experience of Brief Admissions as a gift was structured by the following constituents: 'a sense of safety and containment', 'liberation from a hostage situation', 'a return to wellbeing', and 'catalysts for relational shifts'. In contrast, the constituents of the experience of being robbed included 'a tug of war for control', 'an unworthy wasteland', 'abandonment and collapse of authority', and 'no sense of purpose and plan'.

CONCLUSIONS

Brief Admissions may come across as challenging, futile and painful in the life of the parent, yet they may also support a process of recovery and healthy development for the entire family. To realize the full potential of the intervention, mental health professionals providing Brief Admission must be mindful of the challenges the parent may face as their teenager starts self-admitting, tactfully and sensitively preparing the parent for a new parental role.

A cross-sectional study exploring the positive aspects of caregiving in opioid dependence and its relation with quality of life, social support, and caregivers' burden

Background and Aims

Despite a large body of research linking caregiver burden and social support in substance dependence, positive aspects of caregiving in these disorders have received very minimal attention. This exploratory observational study aimed to assess the positive aspects of caregiving for opioid dependence and evaluate the association of these positive aspects with caregiver quality of life, burden, and social support.

Methods

This cross-sectional study included 199 caregivers of patients with opioid dependence recruited through purposive sampling. Participants were assessed using the Scale for Positive Aspects of Caregiving Experience (SPACE), World Health Organization Quality of Life-BREF version, Family Burden Interview Schedule (FBIS), and Social Support Questionnaire.

Results

Of the 199 caregivers recruited, a majority of the caregivers were middle-aged women. About two-thirds of the patients were currently using opioids (n = 135, 67.8%), while the remaining were abstinent. Among the SPACE domain scores, the mean was highest for motivation for the caregiving role (2.07), which was followed by self-esteem and social aspect of caring (2.04), caregiving personal gains (1.76), and caregiver satisfaction (1.65). Caregivers of patients currently abstinent experienced greater positive aspects of caregiving (SPACE mean item score 2.57 versus 1.62, P < 0.001), and lesser burden (FBIS mean score 13.4 versus 29.3, P < 0.001).

Conclusion

Positive aspects of caregiving can be potentially utilized for better caregiver engagement in treatment and improved caregiver outcomes.

A Novel Scale to Assess Parental Satisfaction of Dental Local Anesthetic Techniques in Children: A Cross-Sectional Study

Background

Pain control is one of the most important aspects that can affect parental satisfaction of the dental care provided for children. Dental local anesthesia has the highest impact on pain sensation of the children. However, there is no scale in the literature to assess parental satisfaction of dental local anesthetic techniques.

Objectives

This study was aimed to assess the parental satisfaction with dental local anesthetic techniques for their children through designing a scale that reflects satisfaction and to study the validity and reliability of this scale.

Methods

A cross-sectional observational study was conducted on 150 parents (102 mothers and 48 fathers). Two techniques of local anesthesia were used for each child participated in this study (inferior alveolar nerve block and computerized intraosseous anesthesia). The developed scale consisted of 20 items in a 5-point Likert scale. Half of the items were written in a negative format. Internal consistency, validity, and factor analysis were performed in this study. Independent t-test was used to compare between the two techniques of anesthesia, between boys and girls and among fathers and mothers.

Results

Parental satisfaction mean values were higher in the computerized intraosseous anesthesia group in comparison to inferior alveolar nerve block (P value <0.05). The T-test showed that there was no difference between boys and girls regarding parental satisfaction (P value >0.05). Furthermore, fathers show lower satisfaction in the computerized interosseous anesthesia group (P value <0.05). Excellent internal consistency of this scale was resulted as Cronbach's alpha reliability coefficient was 0.985. After factor analysis, seven factor components were retained by using varimax rotation.

Conclusions

Findings of this study reported that the designed parental satisfaction of dental local anesthetic techniques scale (PSLAS) is a valid and reliable scale to be used. Moreover, this study showed that parental satisfaction was higher when computerized intraosseous anesthesia was used in comparison to inferior alveolar nerve block.

The association of attachment, mentalization and reflective functioning with mental health in gender diverse children and adolescents: A systematic review

Gender diverse children (here defined as minors under 18) face greater risk for depression, anxiety and suicidality than their cisgender peers. This situation calls for research on protective factors of mental health in this population, and on appropriate therapeutic and supportive interventions. This systematic review aimed at (1) examining literature on the role of attachment, mentalization and reflective functioning in protecting mental health of gender diverse children and identifying the mental health outcomes that have been assessed; and (2) outlining interventions based on attachment, mentalization and reflective functioning that have been proposed. The work was conducted according to the PRISMA guidelines. Fifty-one studies were identified and 9 met the inclusion criteria. Results indicate that, besides a general protective role for mental health, attachment, mentalization and reflective functioning moderate and mediate, through different pathways, (1) the association between gender diversity and emotional/behavioural problems; and (2) the negative effects of minority stress. Mentalization seems to be an individual resilience factor; the capacity of the caregiver to serve as a secure base and validate the internal experience of incongruence of the child promote a healthy psychological development. Three levels of action for interventions were identified: individual, family and community.

Indigeneity and Likelihood of Discharge to Psychiatric Hospital in an Australian Deliberate Self-Poisoning Hospital-Treated Cohort

Hospital-treated self-harm rates for Aboriginal and Torres Strait Islander (Indigenous) people are at least double those for other Australians. Despite this, limited research has explored the relationship between Indigeneity and the clinical management of hospital-treated deliberate self-harm. A retrospective clinical cohort study (2003-2012) at a regional referral centre (NSW) for deliberate self-poisoning was used to explore the magnitude and direction of the relationship between Indigeneity and discharge destination (psychiatric hospital vs. other) using a series of logistic regressions. There were 149 (4%) Indigenous and 3697 (96%) non-Indigenous deliberate self-poisoning admissions during the study period. One-third (31%) were referred to the psychiatric hospital at discharge; Indigenous 21% (n = 32) vs. non-Indigenous 32% (n = 1175). Those who identified as Indigenous were less likely to be discharged to the psychiatric hospital, OR 0.59 (0.40-0.87) at the univariate level, with little change after sequential adjustment; and AOR 0.34 (0.21-0.73) in the fully adjusted model. The Indigenous cohort had a lower likelihood of psychiatric hospital discharge even after adjustment for variables associated with discharge to the psychiatric hospital highlighting the need for further investigation of the reasons accounting for this differential pattern of clinical management and the effectiveness of differential after-care allocation.

A novel application of the Lego® Serious Play® methodology in mental health research: Understanding service users' experiences of the 0-19 mental health model in the United Kingdom

AIM

The 0-19 model is an example of a service that has been retransformed in line with UK's recent policies. However, there is limited qualitative research exploring young people's experiences with the accessibility and acceptability of retransformed models through more participatory qualitative approaches. This study aimed to understand service users' experiences of accessibility and acceptability with the 0-19 model and its service provision. In addition, we also aim to outline the process and application of the Lego® Serious Play® methodology to the context of children and young people's mental health research and reflect on the usefulness of this novel approach and its potential for further research use.

METHODS

A qualitative methodology based on the Lego® Serious Play® approach was used to investigate service users' perceptions of the accessibility and acceptability of the 0-19 model. This novel approach is viewed as a facilitator of engagement, which also stimulates critical thinking and reflective practice. All interviews were thematically analysed.

RESULTS

Seven participants constructed 14 models and provided metaphorical narratives for them besides engaging in group discussions. Thematic analysis of the participants' models and narratives resulted in six identified themes: accessibility, doors into the unknown, let it out, overcoming obstacles, less is sometimes better and satisfaction with the 0-19 model and its provision.

CONCLUSION

Participants in this study perceived the 0-19 model as acceptable and, to a degree, accessible. Participants identified a range of barriers to accessibility, such as inconvenient locations, long waiting and inflexible working times.

How, for Whom, and in Which Contexts or Conditions Augmented and Virtual Reality Training Works in Upskilling Health Care Workers: Realist Synthesis

Background

Using traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation.

Objective

The aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance.

Methods

We conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration.

Results

Of the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration.

Conclusions

Technical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations.

A New Acute-At-Home Child and Adolescent Clinical Service: Evaluation of Impact

OBJECTIVE

An Acute at Home (AAH) clinical service was implemented to reduce emergency and inpatient admissions to the regional tertiary child and adolescent mental health system. This paper examines describes the served the population and impact on emergency and inpatient admissions.

METHODS

Analysis of re-admission rates for those enrolled before and after the May 2019 implementation of the AAH service in comparison over the same time period to an unexposed comparison group. In addition the groups were compared on clinical and demographic variables comparing those exposed and those not exposed to the AAH service.

RESULTS

The results indicated that the AAH group experienced reduced rates of readmission and lengths of stay post-exposure. Family composition, sex, seven Adverse Childhood Experience survey items, and nine Western Canada Waitlist Child Mental Health Priority Criteria Score items distinguished those exposed to AAH compared to those who were not. Thirteen of 19 independent variables indicated greater pathology in the AAH group with less likelihood of potential of danger to self.

CONCLUSION

The present results indicate a substantial benefit of the AAH service via reducing readmissions and lengths of stay. The quantitative measures warrant a careful qualitative examination of the AAH processes along with ongoing monitoring of the program's effect.

Bridging the gap between the emergency department and outpatient care: feasibility of a short-term psychiatric crisis intervention for children and adolescents

Child and adolescent mental health systems are facing limited resources of available psychosocial interventions, often leading to long waiting lists for acceptance to treatment. We describe the feasibility of a short-term (8-10 sessions) psychological crisis intervention (CI) protocol for children and adolescents aged 8-17 years (n = 30, mean ± standard deviation 12.9 ± 2.4 years) who were referred to an outpatient mental health clinic due to suicidal ideation, aggression, severe anxiety, or extreme family conflict. The participants were assessed before and after the CI, and at a 3-6-months follow-up visit. The psychiatric assessments included clinical evaluation by a senior psychiatrist, and the completion of self-report questionnaires by both the participants and their parents. Following the establishment of the CI unit, the waiting lists for urgent cases were reduced from a median of 84 days in the two preceding years to 23 days in the following 3 years (H[2] = 18.5, p < 0.0001) for patients of the CI unit. A 1-year psychiatric follow-up after the end of the CI revealed that 72% did not require additional psychotherapy. The overall clinical evaluation measures (clinical evaluation, parents-report and child report) improved and had been preserved at the 3-6-months follow-up. Our results demonstrate the feasibility of a short-term CI protocol for expediting admission to treatment for urgent psychiatric cases.

Physicians' Use of the Computerized Physician Order Entry System for Medication Prescribing: Systematic Review

BACKGROUND

Computerized physician order entry (CPOE) systems in health care settings have many benefits for prescribing medication, such as improved quality of patient care and patient safety. However, to achieve their full potential, the factors influencing the usage of CPOE systems by physicians must be identified and understood.

OBJECTIVE

The aim of this study is to identify the factors influencing the usage of CPOE systems by physicians for medication prescribing in their clinical practice.

METHODS

We conducted a systematic search of the literature on this topic using four databases: PubMed, CINAHL, Ovid MEDLINE, and Embase. Searches were performed from September 2019 to December 2019. The retrieved papers were screened by examining the titles and abstracts of relevant studies; two reviewers screened the full text of potentially relevant papers for inclusion in the review. Qualitative, quantitative, and mixed methods studies with the aim of conducting assessments or investigations of factors influencing the use of CPOE for medication prescribing among physicians were included. The identified factors were grouped based on constructs from two models: the unified theory of acceptance and use of technology model and the Delone and McLean Information System Success Model. We used the Mixed Method Appraisal Tool to assess the quality of the included studies and narrative synthesis to report the results.

RESULTS

A total of 11 articles were included in the review, and 37 factors related to the usage of CPOE systems were identified as the factors influencing how physicians used CPOE for medication prescribing. These factors represented three main themes: individual, technological, and organizational.

CONCLUSIONS

This study identified the common factors that influenced the usage of CPOE systems by physicians for medication prescribing regardless of the type of setting or the duration of the use of a system by participants. Our findings can be used to inform implementation and support the usage of the CPOE system by physicians.

Barriers, enablers, and opportunities for organisational follow-up of workplace violence from the perspective of emergency department nurses: a qualitative study

BACKGROUND

A lack of follow-up of violence incidents and assaulted staff has been associated with high levels of workplace violence. There is a paucity of literature on the barriers, enablers and opportunities for organisational follow-up of workplace violence. The aim of this study was to explore the barriers, enablers and opportunities for organisational follow-up of workplace violence from the perspective of Emergency Department nurses.

METHODS

This qualitative study comprised two focus groups with Emergency Department nurses. Data were analysed thematically. COREQ guidelines were followed for the design and reporting of the study.

RESULTS

The barriers to follow-up in this study relate to the type of perpetrator, the initial incident response, the incident reporting process and organisational action. The enablers included hospital initiatives to manage violence and support staff wellbeing. The opportunities included strategies to improve follow-up and ideas for new follow-up strategies.

CONCLUSIONS

Organisational follow-up is important for the emotional and professional wellbeing of staff who experience workplace violence. Opportunities for follow-up include exploring different approaches to patients with mental health issues and focussing on reoffenders by providing appropriate support and consequences. Managers should advocate for efficient and standardised reporting processes and ensure assaulted staff have a clear perception of follow-up and are included in the follow-up process. Including the perpetrators in the follow-up process may reduce workplace violence.