Situational vulnerability within mental healthcare - a qualitative analysis of ethical challenges during the COVID-19 pandemic.

BACKGROUND: Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability. METHODS: We present the results of a retrospective qualitative analysis of a survey of ethical challenges in different mental healthcare facilities of a large regional mental healthcare provider in Germany. We evaluate them ethically using a dynamic and situational understanding of vulnerability. RESULTS: Difficulties in implementing infection prevention measures, restrictions of mental health services in favor of infection prevention, social isolation, negative health effects on mental healthcare users and patients, and challenges in implementing regulations on state and provider levels within the local specificities emerged across different mental healthcare settings as ethically salient topics. CONCLUSIONS: Applying a situational and dynamic understanding of vulnerability allows the identification of specific factors and conditions that have contributed to an increased context-dependent vulnerability for mental healthcare users and patients. These factors and conditions should be considered on the level of state and local regulations to reduce and address vulnerability.

[Outsourcing of nursing staff costs in psychiatry? : A secondary data analysis of possible effects on the remuneration system in psychiatry]. / Ausgliederung der Pflegekosten in der Psychiatrie? : Eine Sekundärdatenanalyse möglicher Auswirkungen auf das PEPP-System.

BACKGROUND: Nursing staff were excluded from the German DRG system for somatic hospital treatment and will be funded separately in the future. In psychiatry and psychosomatic medicine, binding personnel requirements have been defined but there has been no regulation of how these personnel requirements are adequately financed. OBJECTIVE: The objective of this study was to analyze the costs of inpatient psychiatry and psychosomatic medicine and to evaluate possible effects of funding nursing staff separately. MATERIAL AND METHODS: This analysis is based on aggregated daily treatment costs of selected hospitals (data year 2018), which annually submit their performance and cost data to the Institute for the Hospital Remuneration System (InEK) for the empirical further development of the remuneration system. RESULTS: Nursing staff represent the largest cost factor in inpatient psychiatry and psychosomatic medicine. Excluding nursing staff drastically reduces the variance of psychiatric DRG renumeration and even exceeds its proportion of the total costs. After outsourcing nursing costs, psychiatric DRGs achieve only a very limited cost separation. CONCLUSION: The binding personnel requirements necessitate adequate financing of nursing staff. This raises the debate about the further development of psychiatric remuneration. The question arises as to whether the effort associated with using the psychiatric DRG system justifies its usefulness as an instrument for budgeting when core functions such as cost separation are only given to a limited extent. Alternative approaches to budgeting should also be examined for putting costs and benefits in a better ratio.

[DGPPN pilot study on the implementation of the S3 guideline "Prevention of coercion: prevention and therapy of aggressive behavior in adults"]. / DGPPN-Pilotstudie zur Implementierung der S3-Leitlinie "Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsenen".

OBJECTIVE: To investigate whether implementation recommendations derived from the German guidelines "Prevention of coercion" can be implemented on acute psychiatric wards by means of implementation consultants into ward work and if this contributes to an increased level of adherence to guideline intervention recommendations approved by the DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde)? MATERIAL AND METHODS: Two medical or nursing experts advised ward teams on the implementation of three individually selected recommendations from the guidelines in a structured consulting process over 6 months. The degree of implementation of the recommendations was assessed before and after the intervention by the ward teams together with the implementation consultants using a tool developed for this purpose (PreVCo rating tool). RESULTS: A total of five wards responsible for compulsorily admitted patients took part in the pilot study; three of them completed the intervention. On all three wards, implementation of the guideline recommendations improved for both selected and unselected recommendations. The strategy of using implementation consultants as well as the application of the PreVCo rating tool were well accepted and considered feasible by both the treatment teams and the implementation consultants. CONCLUSION: This pilot study showed that an implementation of recommendations on psychiatric wards derived from the German guidelines "Prevention of coercion" supported by implementation consultants is feasible, well acceptable among treatment teams and can lead to positive changes. The sample of five wards with diverse patient profiles was convincing. The efficacy in terms of reduction of coercive measures is currently being investigated in a randomized controlled trial on 55 psychiatric wards in different parts of Germany, with an intervention based on this pilot study.

Primary dementia care based on the individual needs of the patient: study protocol of the cluster randomized controlled trial, DemStepCare.

BACKGROUND: Most people with dementia (PwD) are cared for at home, with general practitioners (GPs) playing a key part in the treatment. However, primary dementia care suffers from a number of shortcomings: Often, diagnoses are made too late and therapies by GPs do not follow the guidelines. In cases of acute crises, PwD are too often admitted to hospital with adverse effects on the further course of the disease. The aim of this study is to implement and evaluate a new GP-based, complex dementia care model, DemStepCare. DemStepCare aims to ensure demand-oriented, stepped care for PwD and their caregivers. METHODS/DESIGN: In a cluster randomized controlled trial, the care of PwD receiving a complex intervention, where the GP is supported by a multi-professional team, is compared to (slightly expanded) usual care. GPs are clustered by GP practice, with 120 GP practices participating in total. GP practices are randomized to an intervention or a control group. 800 PwD are to be included per group. Recruitment takes place in Rhineland-Palatinate, Germany. In addition, a second control group with at least 800 PwD will be formed using aggregated routine data from German health insurance companies. The intervention comprises the training of GPs, case management including repeated risk assessment of the patients' care situation, the demand-oriented service of an outpatient clinic, an electronic case record, external medication analyses and a link to regional support services. The primary aims of the intervention are to positively influence the quality of life for PwD, to reduce the caregivers' burden, and to reduce the days spent in hospital. Secondary endpoints address medication adequacy and GPs' attitudes and sensitivity towards dementia, among others. DISCUSSION: The GP-based dementia care model DemStepCare is intended to combine a number of promising interventions to provide a complex, stepped intervention that follows the individual needs of PwD and their caregivers. Its effectiveness and feasibility will be assessed in a formative and a summative evaluation. TRIAL REGISTRATION: German Register of Clinical Trials (Deutsches Register Klinischer Studien, DRKS), DRKS00023560 . Registered 13 November 2020 - Retrospectively registered. HTML&TRIAL_ID=DRKS00023560.

[Treatment clusters and personnel assessment in psychosomatic medicine and psychotherapy - results of a feasibility study of the platform model]. / Behandlungscluster und Personalbemessung in der psychosomatischen Medizin und Psychotherapie ­ Ergebnisse einer Machbarkeitsstudie zum Plattformmodell.

Treatment clusters and personnel assessment in psychosomatic medicine and psychotherapy - results of a feasibility study of the platform model Objectives: In accordance with the legal requirements of the PsychVVG, it is necessary to develop criteria for inpatient and day-care psychosomatic psychotherapeutic care, which can be used to determine the appropriate staffing for different treatment areas and different care structures. For psychosomatic medicine and psychotherapy a model with four treatment clusters was developed, which is oriented on the one hand to the psychotherapeutic intensity and on the other hand to the medical expenditure. Method: In three consecutive rounds with up to 30 experts, representative selected from the three institution types university hospital, departmental psychosomatic medicine and specialized clinic, the minute values per patient required for a treatment according to the guidelines were determined using the Delphi method. Newly developed activity profiles for the six occupational groups were used, which allow the recording of all patient- and setting-related activities. Results: With the results of the feasibility study, an instrument has been developed for the first time to determine the requirements of staffing in psychosomatic medicine. Convergent minute values could be formulated for three of the four treatment clusters. Conclusions: The provision of care in psychosomatic medicine and psychotherapy is complex, so that a limitation to four treatment areas is only possible if significantly more generous equivalence rules are applied between the professional groups than those laid down in the PPP Directive.

[Staffing of inpatient psychiatric facilities : A patient-oriented and guideline-oriented staffing concept]. / Personalausstattung in stationären psychiatrischen Einrichtungen : Ein patientenorientiertes und leitliniengerechtes Konzept zur Personalbemessung.

BACKGROUND AND GOAL: According to § 136a (2) SGB V (volume V of the German Social Security Code) the German legislator instructed the Federal Joint Committee (G-BA) to specify binding minimum standards for the staff needed for the treatment in inpatient psychiatric and psychosomatic facilities. This induced the expert associations/organizations to develop their own conceptional approach as to the future organization of staffing. METHOD: Organization of regular expert workshops, the results of which were systematically documented and validated by the experts. RESULTS: The essential elements of the concept are: the starting points for the calculation are the needs of all patients treated in the institution. The need for treatment has three dimensions: (a) psychiatric psychotherapeutic/psychosomatic psychotherapeutic/pediatric and adolescent psychiatric-psychotherapeutic, (b) somatic and (c) psychosocial needs. The model developed by the platform distinguishes between staff requirements being directly related to the treatment of the individual patient, staff requirements caused by the treatment setting and such staff requirements arising at an institutional level. Minimum staff requirement is understood as the staff structure which is, among others, needed to guarantee the multiprofessional, physician-led treatment and the required medical care services for all patients specified by the existing guidelines or an expert consensus as well as to ensure the protection of the patient, fellow patients and the employees working in the facility against hazards. CONCLUSION: This model considers the medical progress within the meaning of the evidence-based guidelines and the modified healthcare practice including sociopolitical standards aimed at the patients' self-determination.

[Low-Intensity Cognitive Behavioral Therapy (LI-CBT) - An Introduction in Concepts and Framework]. / Low-Intensity Cognitive Behavioral Therapy (LI-CBT) ­ Eine Einführung in Konzepte und Rahmenbedingungen.

Low-intensity cognitive behavioural therapy (LI-CBT) depicts interventions that aim at increasing access to evidence-based psychological therapies. This is achieved by (1) reducing the amount of time in which the practitioner is in contact with individual patients, (2) using practitioners that have been specifically trained to deliver low intensity interventions and without any prior formal health professional qualifications and (3) use of interventions with varying intensity. Stepped care and collaborative care constitute the organizational frame to deliver low-intensity interventions. Whereas large-scale research and health service projects abroad are focussing on LI-CBT, research in German is lagging far behind. Particularly in the light of the growing demands and utilization of mental health care as well as governmental claims to develop and evaluate new forms of providing mental health services, LI-CBT represents a promising approach.

["Nicht von schlechten Eltern - NischE": A Family Orientated Collaborative Care Approach to Support Children in Families with Mentally Ill Parents]. / Nicht von schlechten Eltern ­ NischE: Ein Brückenkonzept familienorientierter Versorgung von Kindern mit psychisch oder suchtbelasteten Eltern.

"Nicht von schlechten Eltern - NischE": A Family Orientated Collaborative Care Approach to Support Children in Families with Mentally Ill Parents The present work describes the setting- and multi-professional offer "NischE" in Gütersloh, a systemic approach for the care of children and their mentally ill parents. Children of mentally ill parents are a special risk group for developing their own mental illness. The aim of the collaborative care model between child and adolescent psychiatry, youth services and adult psychiatry is to enable affected families in terms of family-focused practice a low threshold access to different services. For this purpose, two positions have been created to advise the affected families and support access to the help system in the sense of a systemic case management in a project. The article describes the background and the need for the development of the offer, the current scientific knowledge base on the subject and illustrates the procedure using a case study from practice.

[DemStepCare: Risk-stratified support for primary care-based dementia care - evaluation from general practitioner's view]. / DemStepCare: Risikostratifizierte Unterstützung der ambulanten Demenzversorgung ­ Bewertung aus hausärztlicher Perspektive.

OBJECTIVE: The innovation fund project DemStepCare aimed to optimize multi-professional care through case management, risk stratification, and crisis outpatient clinic. Here, the evaluation results from the perspective of the general practitioners are presented. METHODS: A quantitative survey was carried out at three time points regarding acceptance, benefit assessment and sensitivity to dementia of the general practitioners. In addition, qualitative interviews were conducted. RESULTS: Satisfaction with the overall project was high. Added value and relief factors were perceived and more effective and stable dementia care was achieved through collaboration with case management. Physicians reported increased subjective competence in diagnostics and disease management. CONCLUSIONS: The results confirm the benefit and effectiveness of DemStepCare from general practitioner's perspective.

[German translation of Suicidal Patient Observation Chart (SPOC) - an instrument for practice]. / Deutsche Übersetzung des Suicidal Patient Observation Charts (SPOC) - ein Instrument für die Praxis.

Nursing of suicidal in-patients is a complex and responsible task. A direct and immediate intensive caring and therapeutic supervision, also known as special observation is still recommended in guidelines (DGPPN, 2012) and maybe one of the most used interventions in the caring of suicidal patients in inpatient settings. It involves many kinds to develop the relationship between the observer and the patient. The original SPOC was developed in Sweden with the aim to increase the quality of a systematically documentation during the supervision of suicidal patients. It is an instrument to ensure systematic documentation of observational behavior or noticeable mood during acute suicidal crisis, for example feelings like "worried, anxious" or other possible influencing factors like "sudden mood variation". By this means the SPOC can ensure the process of systematic documentation of special observation and increase its quality, i. e. who documented what at what time. Furthermore SPOC can facilitate a better communication of the observation process to the multidisciplinary team and to the patient as well. The SPOC includes the 28 items and covers 24 separate observation periods. The aim of this paper is to constitute the translation process from the English to the German SPOC version. The translation process followed a five step model. In the first step the English version was translated from two German native speakers. In the second step, the first two translation results where discussed by the Expert group (authors) and a new version was developed. In the third step the first german version was translated back (two English native Speakers) into English. The fourth step was taken, to review the results by the expert groups (authors) and set up the so called "pre version". The last step includes the proof of content validity by 52 nurses. The proof was able to identify a few misunderstandings and helped to enhance the tool in its final version. With the translation, the German-speaking nursing practice in psychiatry has a tool that can be used by psychiatric nurses regarding their complex interventions to be undertaken in this special group of patients.

Lead exposure of mainland Australia's top avian predator.

Lead (Pb) toxicity, through ingestion of lead ammunition in carcasses, is a threat to scavenging birds worldwide, but has received little attention in Australia. We analyzed lead exposure in the wedge-tailed eagle (Aquila audax), the largest raptor species found in mainland Australia and a facultative scavenger. Eagle carcasses were collected opportunistically throughout south-eastern mainland Australia between 1996 and 2022. Lead concentrations were measured in bone samples from 62 animals via portable X-ray fluorescence (XRF). Lead was detected (concentration >1 ppm) in 84% (n = 52) of the bone samples. The mean lead concentration of birds in which lead was detected was 9.10 ppm (±SE 1.66). Bone lead concentrations were elevated (10-20 ppm) in 12.9% of samples, and severe (>20 ppm) in 4.8% of samples. These proportions are moderately higher than equivalent data for the same species from the island of Tasmania, and are comparable to data from threatened eagle species from other continents. Lead exposure at these levels is likely to have negative impacts on wedge-tailed eagles at the level of the individual and perhaps at a population level. Our results suggest that studies of lead exposure in other Australian avian scavenger species are warranted.

[Long Term Evaluation of the Implementation of the Safewards Model - Results of a Follow-Up-Study Among Patients and Staff in Acute Psychiatric Wards]. / Langzeitevaluation der Implementierung des Safewards-Modells ­ Ergebnisse einer Follow-Up-Erhebung unter Patient*innen und Mitarbeitenden der Akutpsychiatrie.

OBJECTIVE: Evaluation of long-term effects of the implementation of the Safewards Model (SM) among staff and patients in acute psychiatry in Germany. METHOD: Assessment of ward atmosphere, job satisfaction, fidelity, and coercive interventions in 2 locked wards directly before and 15 months after implementation of the SM. RESULTS: Ward atmosphere was assessed significantly better after implementation, job satisfaction was still above-average at both times, coercive interventions declined significantly in one ward, fidelity and degree of implementation were still high. CONCLUSIONS: The implementing of the SM in locked wards in acute psychiatry can also have positive effects in long run.

Habitat selection by vulnerable golden bandicoots in the arid zone.

In 2010, vulnerable golden bandicoots (Isoodon auratus) were translocated from Barrow Island, Western Australia, to a mainland predator-free enclosure on the Matuwa Indigenous Protected Area. Golden bandicoots were once widespread throughout a variety of arid and semiarid habitats of central and northern Australia. Like many small-to-medium-sized marsupials, the species has severely declined since colonization and has been reduced to only four remnant natural populations. Between 2010 and 2020, the reintroduced population of golden bandicoots on Matuwa was monitored via capture-mark-recapture data collection, which was used in spatially explicit capture-recapture analysis to monitor their abundance over time. In 2014, we used VHF transmitters to examine the home range and habitat selection of 20 golden bandicoots in the enclosure over a six-week period. We used compositional analysis to compare the use of four habitat types. Golden bandicoot abundance in the enclosure slowly increased between 2010 and 2014 and has since plateaued at approximately one quarter of the density observed in the founding population on Barrow Island. The population may have plateaued because some bandicoots escape through the fence. Golden bandicoots used habitats dominated by scattered shrubland with spinifex grass more than expected given the habitat's availability. Nocturnal foraging range was influenced by sex and trapping location, whereas diurnal refuge habitat, which was typically under a spinifex hummock with minimal overstory vegetation, was consistent across sex and trapping location. Our work suggests that diurnal refuge habitat may be an important factor for the success of proposed translocations of golden bandicoots.

Mus musculus populations in Western Australia lack VKORC1 mutations conferring resistance to first generation anticoagulant rodenticides: Implications for conservation and biosecurity.

BACKGROUND: Humans routinely attempt to manage pest rodent populations with anticoagulant rodenticides (ARs). We require information on resistance to ARs within rodent populations to have effective eradication programs that minimise exposure in non-target species. Mutations to the VKORC1 gene have been shown to confer resistance in rodents with high proportions of resistance in mice found in all European populations tested. We screened mutations in Mus musculus within Western Australia, by sampling populations from the capital city (Perth) and a remote island (Browse Island). These are the first Australian mouse populations screened for resistance using this method. Additionally, the mitochondrial D-loop of house mice was sequenced to explore population genetic structure, identify the origin of Western Australian mice, and to elucidate whether resistance was linked to certain haplotypes. RESULTS: No resistance-related VKORC1 mutations were detected in either house mouse population. A genetic introgression in the intronic sequence of the VKORC1 gene of Browse Island house mouse was detected which is thought to have originated through hybridisation with the Algerian mouse (Mus spretus). Analysis of the mitochondrial D-loop reported two haplotypes in the house mouse population of Perth, and two haplotypes in the population of Browse Island. CONCLUSIONS: Both house mouse populations exhibited no genetic resistance to ARs, in spite of free use of ARs in Western Australia. Therefore weaker anticoagulant rodenticides can be employed in pest control and eradication attempts, which will result in reduced negative impacts on non-target species. Biosecurity measures must be in place to avoid introduction of resistant house mice, and new house mouse subspecies to Western Australia.

Completing a worldwide picture: preliminary evidence of lead exposure in a scavenging bird from mainland Australia.

Lead toxicity from ammunition has been shown to be a threat to scavenging birds across the globe. Despite decades of research in Europe, North and South America, Asia and Africa, there have been no studies to investigate this phenomenon in Australia despite that continent having many species of scavenging birds and widespread shooting practices. We present preliminary evidence of lead exposure in Australia's largest bird of prey, the wedge-tailed eagles (Aquila audax) through analysis of bone and eggshell samples from south-western Australia. From 11 bone samples, three birds (27%) had lead levels exceeding literature thresholds for elevated levels (>6.75 ppm). From 36 eggshell samples, no samples had lead levels >0.5 ppm, suggesting some limitations for this matrix as an indicator of lead exposure. Isotope ratios suggested ammunition as a likely source of the lead found in bone samples with elevated lead levels but other potential sources of lead require further investigation. Our preliminary results demonstrate that lead exposure is occurring in scavenging birds in Australia, and like the rest of the world, is likely to be derived from ammunition. This study supports an urgent call for further research into this worldwide phenomenon in Australia.

Corrigendum: Preventing and Reducing Coercive Measures-An Evaluation of the Implementation of the Safewards Model in Two Locked Wards in Germany.

[This corrects the article DOI: 10.3389/fpsyt.2019.00340.].

[Changes on Ward Atmosphere and Job Satisfaction after Implementation of the Safewards Model in Two Locked Acute Psychiatric Wards - A Multi-Perspective Evaluation]. / Veränderungen des Stationsklimas und der Arbeitszufriedenheit nach Einführung des Safewards-Modells auf zwei geschützten akutpsychiatrischen Stationen ­ Eine multiperspektivische Evaluation.

OBJECTIVE: Evaluation of the changes of ward atmosphere and job satisfaction after the implementation of the Safewards model in acute psychiatry in Germany. METHOD: A multi-perspective pre-post study design was conducted in two locked wards among patients (n = 80) and staff (n = 88) before and after the implementation of the Safewards model over a period of 12 months. RESULTS: After the implementation of the Safewards model, ward atmosphere and job satisfaction improved. Both correlated positively amongst staff. Furthermore, job satisfaction correlated positively with a high degree of implementation of two interventions. Fidelity to the Safewards model was high. CONCLUSIONS: Implementing the Safewards model in acute psychiatry with high fidelity can have positive effects on positive ward atmosphere and job satisfaction. Thus, patients as well as staff benefit from this model. With regards to high fluctuation in acute psychiatry, the implementation of the Safewards model can additionally facilitate retention management.

[Perspectives and Opportunities for Psychotherapeutic Interventions in Inpatient Psychiatric Treatment Delivered by Nurses]. / Perspektiven und Chancen für pflegerisch-psychotherapeutische Interventionen in der stationären psychiatrischen Behandlung.

BACKGROUND: Psychotherapy is an essential part of treating people with mental illness. However, the implementation of psychotherapeutic interventions in the field of inpatient psychiatric treatment remains well behind demand. At the same time, the use of psychotherapeutic interventions by other professional groups - such as social workers and nursing - is not a common practice in Germany. OBJECTIVE: What can we learn from the international research with regard to nursing for Germany in view of the insufficient supply of psychotherapeutic care. METHOD: Based on a literature analysis, the German situation of care is related to international developments and a German training curriculum is presented. RESULT: A look at the international literature shows that in other countries especially trained nurses perform psychotherapeutic Interventions. In addition, there are effective training curricula whose transferability to Germany appears to be possible after appropriate adjustments.An 18 months lasting training program for nurses is presented. In addition to disorder-specific competences, this curriculum also provides psychotherapeutic interventions with a general approach. CONCLUSION: Collaborative care in the collaboration of different health professionals has been repeatedly and stably proven to be effective and helpful in treating people with various mental disorders. In order to better meet the growing need for psychotherapeutic interventions in the population in the sense of a stepped care model, trained nurses need to be more involved in the provision of psychotherapeutic services.

Preventing and Reducing Coercive Measures-An Evaluation of the Implementation of the Safewards Model in Two Locked Wards in Germany.

Introduction: Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Materials and Methods: We evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 10 weeks before and 10 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist. Results: Fidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ2 (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ2 (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of admissions decreased significantly [χ2 (1, 182) = 9.30, p = 0.003]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = -2.142, p = 0.032] with an effect size of Cohen's d = -0.282 (95% CI: -0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly. Discussion: Results indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.