Something Happened with the Way We Work: Evaluating the Implementation of the Reducing Coercion in Norway (ReCoN) Intervention in Primary Mental Health Care.

BACKGROUND: Current policies to reduce the use of involuntary admissions are largely oriented towards specialist mental health care and have had limited success. We co-created, with stakeholders in five Norwegian municipalities, the 'Reducing Coercion in Norway' (ReCoN) intervention that aims to reduce involuntary admissions by improving the way in which primary mental health services work and collaborate. The intervention was implemented in five municipalities and is being tested in a cluster randomized control trial, which is yet to be published. The present study evaluates the implementation process in the five intervention municipalities. To assess how the intervention was executed, we report on how its different elements were implemented, and what helped or hindered implementation. METHODS: We assessed the process using qualitative methods. Data included detailed notes from quarterly progress interviews with (i) intervention coordinators and representatives from (ii) user organisations and (iii) carer organisations. Finally, an end-of-intervention evaluation seminar included participants from across the sites. RESULTS: The majority of intervention actions were implemented. We believe this was enabled by the co-creating process, which ensured ownership and a good fit for the local setting. The analysis of facilitators and barriers showed a high degree of interconnectedness between different parts of the intervention so that success (or lack thereof) in one area affected the success in others. Future implementation should pay attention to enhanced planning and training, clarify the role and contribution of service user and carer involvement, and pay close attention to the need for implementation support and whether this should be external or internal to services. CONCLUSIONS: It is feasible to implement a complex intervention designed to reduce the use of involuntary admissions in general support services, such as the Norwegian primary mental health services. This could have implications for national and international policy aimed at reducing the use of involuntary care.

The ReCoN intervention: a co-created comprehensive intervention for primary mental health care aiming to prevent involuntary admissions.

BACKGROUND: Reducing involuntary psychiatric admissions is a global concern. In Norway, the rate of involuntary admissions was 199 per 100,000 people 16 years and older in 2020. Individuals' paths towards involuntary psychiatric admissions usually unfold when they live in the community and referrals to such admissions are often initiated by primary health care professionals. Interventions at the primary health care level can therefore have the potential to prevent such admissions. Interventions developed specifically for this care level are, however, lacking. To enhance the quality and development of services in a way that meets stakeholders' needs and facilitates implementation to practice, involving both persons with lived experience and service providers in developing such interventions is requested. AIM: To develop a comprehensive intervention for primary mental health care aiming to prevent involuntary admissions of adults. METHODS: This study had an action research approach with a participatory research design. Dialogue conferences with multiple stakeholders in five Norwegian municipalities, inductive thematic analysis of data material from the conferences, and a series of feedback meetings were conducted. RESULTS: The co-creation process resulted in the development of the ReCoN (Reducing Coercion in Norway) intervention. This is a comprehensive intervention that includes six strategy areas: [1] Management, [2] Involving Persons with Lived Experience and Family Carers, [3] Competence Development, [4] Collaboration across Primary and Specialist Care Levels, [5] Collaboration within the Primary Care Level, and [6] Tailoring Individual Services. Each strategy area has two to four action areas with specified measures that constitute the practical actions or tasks that are believed to collectively impact the need for involuntary admissions. CONCLUSIONS: The ReCoN intervention has the potential for application to both national and international mental health services. The co-creation process with the full range of stakeholders ensures face validity, acceptability, and relevance. The effectiveness of the ReCoN intervention is currently being tested in a cluster randomised controlled trial. Given positive effects, the ReCoN intervention may impact individuals with a severe mental illness at risk of involuntary admissions, as more people may experience empowerment and autonomy instead of coercion in their recovery process.

Between No Help and Coercion: Toward Referral to Involuntary Psychiatric Admission. A Qualitative Interview Study of Stakeholders' Perspectives.

Objective: Paths toward referral to involuntary psychiatric admission mainly unfold in the contexts where people live their everyday lives. Modern health services are organized such that primary health care services are often those who provide long-term follow-up for people with severe mental illness and who serve as gatekeepers to involuntary admissions at the secondary care level. However, most efforts to reduce involuntary admissions have been directed toward the secondary health care level; interventions at the primary care level are sparse. To adapt effective measures for this care level, a better understanding is needed of the contextual characteristics surrounding individuals' paths ending in referrals for involuntary admission. This study aims to explore what characterizes such paths, based on the personal experiences of multiple stakeholders. Method: One hundred and three participants from five Norwegian municipalities participated in individual interviews or focus groups. They included professionals from the primary and secondary care levels and people with lived experience of severe mental illness and/or involuntary admission and carers. Data was subject to constant comparison in inductive analysis inspired by grounded theory. Results: Four main categories emerged from the analysis: deterioration and deprivation, difficult to get help, insufficient adaptation of services provided, and when things get acute. Combined, these illustrate typical characteristics of paths toward referral for involuntary psychiatric admission. Conclusion: The results demonstrate the complexity of individuals' paths toward referral to involuntary psychiatric admission and underline the importance of comprehensive and individualized approaches to reduce involuntary admissions. Furthermore, the findings indicate a gap in current practice between the policies to reduce involuntary admissions and the provision of, access to, and adaptation of less restrictive services for adults with severe mental illness at risk of involuntary admissions. To address this gap, further research is needed on effective measures and interventions at the primary care level.

Admissions to acute adolescent psychiatric units: a prospective study of clinical severity and outcome.

BACKGROUND: Several countries have established or are planning acute psychiatric in-patient services that accept around-the-clock emergency admission of adolescents. Our aim was to investigate the characteristics and clinical outcomes of a cohort of patients at four Norwegian units. METHODS: We used a prospective pre-post observational design. Four units implemented a clinician-rated outcome measure, the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), which measures mental health problems and their severity. We collected also data about the diagnoses, suicidal problems, family situations, and the involvement of the Child Protection Service. Predictions of outcome (change in HoNOSCA total score) were analysed with a regression model. RESULTS: The sample comprised 192 adolescents admitted during one year (response rate 87%). Mean age was 15.7 years (range 10-18) and 70% were girls. Fifty-eight per cent had suicidal problems at intake and the mean intake HoNOSCA total score was 18.5 (SD 6.4). The largest groups of main diagnostic conditions were affective (28%) and externalizing (26%) disorders. Diagnoses and other patient characteristics at intake did not differ between units. Clinical psychiatric disorders and developmental disorders were associated with severity (on HoNOSCA) at intake but not with outcome. Of adolescents ≥ 16 years, 33% were compulsorily admitted. Median length of stay was 8.5 days and 75% of patients stayed less than a month. Compulsory admissions and length of stay varied between units. Mean change (improvement) in the HoNOSCA total score was 5.1 (SD 6.2), with considerable variation between units. Mean discharge score was close to the often-reported outpatient level, and self-injury and emotional symptoms were the most reduced symptoms during the stay. In a regression model, unit, high HoNOSCA total score at intake, or involvement of the Child Protection Service predicted improvement during admission. CONCLUSIONS: Acute psychiatric in-patient units for adolescents effectively meet important needs for young people with suicidal risks or other severe mental health problems. These units may act in suicide prevention, stabilizing symptom severity at a lower level within a short stay. It is important to explore the differences in outcome, compulsory admissions, and length of stay between units.

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends.

OBJECTIVE: The aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions. METHODS: Combined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas. RESULTS: There are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries. CONCLUSIONS: Databases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

Patients' experiences and clinicians' ratings of the quality of outpatient teams in psychiatric care units in Norway.

OBJECTIVE: Patients' experiences and satisfaction ratings are increasingly used to evaluate quality of care. This study assessed the extent to which outpatient teams, clinics, and health trusts contributed to patients' experiences and to what extent clinicians' evaluations of quality were related to patients' experiences. METHODS: A questionnaire was mailed to 15,422 outpatients who attended Norwegian clinics in September 2004; 43% responded. Patients' experiences were measured on an 11-item index and three subscales: outcomes, interaction with clinicians, and information. Aggregated responses from clinicians were linked to the data on patients' experiences. Multilevel analyses were used to divide the variance between the different organizational levels and to assess the relationship with clinicians' opinions and individual-level factors. RESULTS: Data were analyzed for 6,570 outpatients within 222 teams derived from 89 outpatient clinics within 33 health trusts. Differences in patients' scores were determined largely at the patient level, with teams accounting for 2% of the total variance and organizational levels of clinics and health trusts not contributing to patients' experiences. Team-level clinician quality scores were not significantly associated with patients' experiences. Better experiences were significantly associated with patients' female gender, older age, better self-perceived health, absence of an inpatient history, longer treatment episodes, frequent consultations, and waiting times perceived as acceptable. CONCLUSIONS: The organizational contributions to patients' experience scores were minimal. Although clinicians' ratings of quality are not a substitute for patients' perceptions of quality, surveys of outpatients' experiences and satisfaction may not be appropriate for cross-sectional comparisons of health care providers.

Patients' experience of humiliation in the admission process to acute psychiatric wards.

The objective of the study was to investigate the experiences of humiliations by patients in the admission process to acute psychiatric wards. One-hundred-and-two patients were interviewed within 48 h after hospitalization about their experiences of the admission process. The structured Admission Experience Survey questionnaire was used to identify negative events of the admission process. Perceived humiliation was defined by a cut-off on the self-reported Cantrill's Ladder Scale. Six qualitative depth interviews of patients with high and low humiliation scores were performed in order to relate interview information on humiliation experiences to the self-report. Negative events during the admission process were significantly more common among patients with involuntary admission, but were also observed among those voluntary admitted. Humiliation in connection with negative events during the admission process was reported by 48 patients, 24 involuntary and 24 voluntary admitted. In univariate analyses, humiliation was significantly associated with events where the patients were exposed to verbal or physical force, as well as with the conviction that "the admission was not right". In multivariate analyses, the latter conviction was the only significant one, although "use of physical force" also showed a trend (P=0.06). Negative events are common among the routines, procedures, and situations of the admission process to acute psychiatric wards. Some of them can hopefully be modified such as the use of verbal and physical force. In contrast, the conviction that "the admission was not right", which showed the strongest association with humiliation, seems less modifiable in the admission process.

Discrepancies between patients and professionals in the assessment of patient needs: a quantitative study of Norwegian mental health care.

BACKGROUND: Sensitivity to and respect for the user perspective are important facets of user-centred services and empowerment in contemporary mental health care. Little is known about the extent to which new policies influence mental health work in practice. AIMS: To investigate discrepancy between patients and professionals in the assessment of patient needs. Analyses could indicate emphasis on user orientation in Norwegian mental health care. METHODS: Patients and their respective health professionals (n = 1080) completed separate questionnaires regarding patient characteristics and needs. Identifiers were removed from the data locally and then entered into a national database. Descriptive statistics and multiple regression analysis were used to explore mean levels of discrepancy and predictors of discrepancy. RESULTS: Mean discrepancy was low, as, on average, 30 of the listed 40 needs were considered absent by both the patients and their respective professional. However, the parties showed distinct disagreement as to the amount and type of needs that were present. Specifically, professionals identified more needs than patients (9.3 vs. 4.3, respectively) and this difference was characterized by a strong professional emphasis on needs regarding professional monitoring and follow-up. Results showed that symptoms of severe cognitive disability were over-represented in the group of patients with the highest level of discrepancy, however, the majority of high-discrepancy patients were not severely disabled on cognitive functions. A multiple regression analysis revealed 10 predictors of high discrepancy. DISCUSSION: A low professional emphasis on user-orientation may be indicated in some cases. Results are discussed with relation to the tension between autonomy and beneficence. Suggestions for practice and further research conclude the paper.