The forensic float nurse: a new concept in the effective management of service delivery in a forensic program.

A major challenge faced by Forensic Program management teams is to balance their budgets due to the unpredictability of the forensic patient population, particularly in the context of managing staffing costs where the hospital is not the "gatekeeper" and does not have control over who is admitted and when. In forensic mental health, the justice system, either via the courts, or review boards, determines who is ordered for admission to hospital for assessment or treatment and rehabilitation. Hospitals have little, if any, recourse but to admit these mentally disordered offenders. This typically results in increased levels of staffing with concomitant overtime costs. The literature suggests that clustered float pool nurses develop enhanced relationships with staff and patients, thereby enabling them to attain specialized clinical expertise to treat specific patient populations, promoting safer, high quality care, and overall are more cost effective. Forensic nursing is recognized as a mental health subspecialty. The "Forensic Float Nurse" concept was piloted to provide readily available, highly adaptable, skilled forensic nurses to assist in times of unpredictably heavy workloads and/or unplanned staffing shortages. A significant reduction approaching 50% in overtime was achieved. Heuristic implications of this finding are presented.

Comprehensive utilization management: the Whitby Psychiatric Hospital model.

One of the main thrusts of the 1990s is increased accountability in the provision of medical and psychiatric services. In response to the pressure to provide more cost-effective services, several initiatives have been implemented to reduce expenditures in health care settings while improving quality of patient care. the most recent introduction of such initiatives is utilization management. Whitby Psychiatric Hospital's comprehensive utilization management program provides a model that can be adapted to any health care facility.

Use of population-specific parameters in generating WAIS-R short forms.

One method of increasing the validity of WAIS-R short forms in estimating the standard WAIS-R Full Scale IQ is by using population-specific parameters in generating WAIS-R short forms. Three studies were conducted to evaluate (1) the contribution of age-scaled scores in generating accurate short-form Full Scale IQ, (2) the psychometric properties (validity and reliability) of WAIS-R subtests with a heterogeneous psychiatric population and subsequent development of short forms based on these properties, and (3) the validity of these short forms with respect to Silverstein's (1982) and Cyr and Brooker's (1984) 2- and 4-subtest combinations. Analyses showed (1) the use of age-scaled scores did not increase validity, (2) different subtest combinations were generated based on the population-specific parameters, and (3) increases in validity occurred for some short forms derived from the clinical sample. Despite increases in validity, clinicians and researchers are cautioned about the use of short forms in clinical practice.

MMPI short forms with adolescents: gender differences in accuracy.

The influence of gender on accuracy for eight short forms of the Minnesota Multiphasic Personality Inventory (MMPI) was investigated using a sample of adolescents. MMPI responses from 318 male and 248 female psychiatric patients, aged 12 to 17, were scored for the standard MMPI, Mini-Mult (using two methods; Kincannon, 1968), Midi-Mult (Dean, 1972), two Maxi-Mults (McLachlan, 1974; Spera & Robertson, 1974), Hugo Short Form (Hugo, 1972), Faschingbauer Abbreviated MMPI (FAM; Faschingbauer, 1974), and MMPI-168 (Overall & Gomez-Mont, 1974). Discrepancy values were obtained for all short-form T-scores by subtracting each short-form T-score from its corresponding standard form T-score. These discrepancy values were analyzed using Gender x Short Form repeated measures multivariate analyses of variance (MANOVAs). Because the number of scales varied among the short forms, two separate analyses were performed, one containing all short forms but only the 11 scales that appeared on all short forms and the other containing all scales but only the three short forms that contained all scales. McLachlan's (1974) Maxi-Mult was excluded from the analysis because of its nearly identical statistical properties to Spera and Robertson's (1974) Maxi-Mult. The interaction was significant on most scales in both analyses. Simple-effects breakdowns of the interactions revealed that the accuracy of each short form differed according to gender on several scales, following no consistent pattern. The Midi-Mult and Maxi-Mult are guardedly recommended as the short forms with the lowest number of scales showing a gender difference; however, the reader is cautioned that this difference is still present in more than one third of the scales. Further research on short-form development is advocated.

Differential classification in school refusal.

It has been argued that school refusal may not be a unitary syndrome, but a common presenting symptom founded on differing underlying dynamics. The paper explores this hypothesis empirically. The clinical files of 100 refusers were scored for several variables which could potentially differentiate between school refusal subtypes, and for several commonly accepted beliefs about school refusal. The data were subjected to a variety of analyses, culminating in cluster analysis. Cluster (C) 1 consisted of children who feared separation from dependent, overprotective mothers. C2 youngsters were perfectionistic and depressed. They dominated mothers who had been deprived in childhood. C3 consisted of extensively disturbed children from multiproblem families, who had suffered early separation or loss, and who were fearful and depressed.

Generalizability of WAIS-R factor structure within and between populations.

We investigated the reliability of the factor structure of the Wechsler Adult Intelligence Scale-Revised (WAIS-R). The WAIS-R subtests, as administered to 146 head-injured males, were factor analyzed. Two- and three-factor solutions were extracted that were consistent with past findings. Congruence coefficients were computed to determine degree of association between factor structures from all samples reported in the literature. All coefficients were impressive. Also, congruence coefficients based on factor structures derived from different samples within the same population were compared to coefficients based on different samples from different populations. No significant discrepancies emerged. Apparently, the slight factor structure variation that does exist is due to chance data fluctuation rather than to systematic population bias. This reflects well on the robustness of the WAIS-R factor structure.

Low IQ samples and WAIS-R factor structure.

Wechsler Adult Intelligence Scale-Revised subtests, as administered to 204 individuals with low IQs, were factor analyzed. Solutions proved comparable to structures extracted from the normative data and to solutions based on WAIS, WISC-R, and WISC data for persons with low IQs. Given the restricted IQ range and diminished variance involved, this study provides a particularly stringent test of WAIS-R factor structure. Subtest contributions to general intelligence, however, tend to be more similar among samples of persons with low IQs than between the present low IQ sample and the standardization sample. Clinicians working with intellectually low functioning clients can validly make factor-based test interpretations, but use of short-forms may be dangerous.

The utility of the MCMI as a DSM-III Axis I diagnostic tool.

The present study examined the utility of the MCMI as a provider of DSM-III Axis I diagnostic hypotheses with a heterogeneous psychiatric inpatient population. Participants represented 31 consecutive referrals made to the psychology department for a clinical and/or diagnostic assessment from a psychiatric rehabilitation unit. Three independent diagnoses derived from the MCMI, a structured interview (DIS), and an unstructured psychiatric interview were obtained for each participant. The percentage agreement between the two criterion diagnoses was 54.8%. Agreement between the MCMI and criterion diagnoses was, at best, 15% for those cases that had an Axis I diagnosis. These findings are in keeping with past research and support the contention that the MCMI is not a useful tool in generating clinically correct or meaningful DSM-III Axis I diagnostic hypotheses.

A replicated cluster solution in a heterogeneous psychiatric population.

Two cluster analytic studies were conducted to explore groupings of patients in a heterogeneous psychiatric population. Study 1 (N = 170) provided support for the derivation by a cluster analytic method of five meaningful clinical groups of patients. Based on an extensively modified inventory and a different population of psychiatric patients, results from Study 2 (N = 224) provided further indication of the stability of the clusters. It was concluded that cluster analysis may provide a viable method as a classification system for a heterogeneous population of psychiatric inpatients.

Factor structure of the SCL-90-R: is there one?

A review of the literature on the factor structure of the Symptom Check List-90-R (SCL-90-R) and its precursors makes evident the many problems inherent in this clinical assessment tool as a measure of independent dimensions of symptom distress, particularly in psychiatric patients. The many versions of the Symptom Check List are evaluated on several criteria (e.g., factor stability, factor loadings, proportion of variance, etc.). It is concluded that interpreting nine dimensions for clinical purposes is highly questionable. It is perhaps still a better measure of general distress as was intended in its original version approximately three decades ago.

School refusal: the heterogeneity of a concept.

Finer discrimination among school refusers may help clear the confusion surrounding the school refusal syndrome. This paper reviews two aspects of the literature-that dealing with etiological theories and that which explicitly addresses the heterogeneity of the school refusal concept. Variables that consistently emerge as potential discriminators among school refusers are identified, and an attempt is made to determine their interrelationships.

Measuring consistency with the Grid Test.

It is argued that the Consistency score derived from the Grid Test of Schizophrenic Thought Disorder is not the most sensitive index of stability between the identical grid forms in identifying the pattern of relations between constructs. The SASD score is proposed as an alternative to the Consistency score. The present study indicates that the SASD score is a more valid measure of the stability between the identical grid forms.