Variation in civil commitment processes across jurisdictions: an approach for monitoring and managing change in mental health systems.

This article demonstrates how unique local factors affect implementation of commitment statutes and, consequently, the extent to which implementation supports fundamental treatment philosophies. Four local variations in the implementation of Ohio's commitment statute are examined with a methodology designed to describe commitment processes. Qualitative case studies highlight factors that appear to contribute to variability across these sites. The authors contend that this information can be used as a system management tool at the state and local levels to (1) suggest needed changes in local service systems, (2) identify specific options/interventions for effecting change in desired directions and (3) assess the extent to which changes affect commitment processes in predictable ways that are consistent with philosophical principles.

Lost in the shuffle: the influence of patient classification scheme on views about the relationship between refusal of medication and involvement in important hospital-based outcomes.

The approach used to classify patients into "refuser" subgroups can influence conclusions about the relationship between refusal of antipsychotic medication and involvement in important hospital-based outcomes such as the need for seclusion and restraint. Use of a cross-sectional taxonomy led to conclusions which were somewhat negatively biased against "refusers." In contrast, use of a longitudinal taxonomy which reflects changes in formal informed consent behavior over time, suggests that it is not refusal, per se, but changes in informed consent status that appear to be associated with problematic behavior. In fact, "consistent-refusers" tended to be the least troublesome of the three informed consent status groups studied. Researchers are encouraged to use patient classification schemes which consider patterns of formal informed consent behavior over time when examining the relationship between refusal and involvement in important outcomes.

Clients' perceptions of involuntary hospitalization.

Because involuntary hospitalization involves the restricting of an individual's autonomy and choice, the challenge in nursing practice is to listen to the client's perceptions and then to set "limits in a humane and least restrictive manner to assure the safety of the client and others" (American Nurses' Association, 1982). However, the danger is that limits may be used to enforce socially desired behavior beyond what is necessary for safety (Garritson, 1983). Study results indicate that clients can clearly offer many specific ideas about their health care experience and needs. These perceptions offer an experiential grounding in the process of offering sensitive, relevant, quality care. Because nursing is a client-centered process, studies on clients' perceptions of care experiences are an area in which nurses can make a major research contribution. Implementation of care based on these client-centered studies could offer significant administrative and practice contributions. The client wants to be heard; nurses have an opportunity to take an active role.