Measuring Quality of Care Received by Suicide Attempters in the Emergency Department.

CONTEXT: Audits conducted on medical records have been traditionally used in hospitals to assess and improve quality of medical care but have yet to be properly integrated and used for suicide prevention purposes. We aimed to (1) revise a quality of care grid and adapt it to an adult population of suicide attempters and (2) identify quality of care deficits in managing adult suicide attempters at the emergency department (ED) in two different Montreal university hospitals. METHODS: An existing checklist for quality of medical and social care in the ED was adapted. A systematic search and data extraction of all suicide attempters in two different Montreal university hospitals were then conducted. All identified individuals who attempted suicide were fully reviewed and quality of care was assessed. RESULTS: Eleven criteria were kept by the expert focus group in the revised grid that was then used to rate 369 individuals that attempted suicide. Suicide risk assessment was only present in 63% of attempters before discharge. Although family history was documented for 90% of attempters, in only 41% of the cases were interviews conducted with relatives. Most discharged patient lacked proper follow-up considering 11% of their relatives received written information on resources in case of need. DISCUSSION: Paper records may be used to systematically assess the quality of care for suicide attempters seen in ED. Results reiterate the need for better suicide prevention strategies for these individuals. The checklist proved to be an excellent assessment of best practices or identification of possible improvements.

Filters in the coping process of people with schizophrenia: A constructivist grounded theory study.

WHAT IS KNOWN ON THE SUBJECT?: In the nursing perspective of Roy's adaptation model, to be adapted means to have positive interactions with one's environment. The ability to use effective coping strategies is an essential ingredient of mental health recovery. However, coping difficulties are often a problem for people with a diagnosis of schizophrenia spectrum disorder, especially those who have inadequate social support. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: "Filters in the coping process" is a grounded theory of coping in people with a diagnosis of schizophrenia spectrum disorder. A filter effect impairs their ability and limits their opportunities to use effective coping strategies. These filters are as follows: to have been helped, to understand in one's own way, to act despite limited freedom and to modulate the process of self-disclosure. "Surface coping" is the product of the effect of these filters on coping attempts and possibilities. It does not reflect the person's real potential. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: By offering an alternative, holistic nursing perspective, the filter model provides the nurse with factors to consider when assessing clients with a diagnosis of schizophrenia spectrum disorder, so as to plan interventions towards improving their coping capacity. By allowing for the presence of surface coping, the nurse will have less tendency to form negative judgments about clients with a diagnosis of schizophrenia spectrum disorder. ABSTRACT: Introduction Numerous studies confirm the coping difficulties of people diagnosed with schizophrenia spectrum disorder, especially those with limited social support. Further, the coping process is itself poorly understood. Aim Starting from a conceptualization of the adaptation of Roy's model, the aim of this study was to describe the coping process of people with schizophrenia spectrum disorder in the context of an inadequate social support. Method A constructivist grounded theorization was performed with a sample of 30 persons with schizophrenia spectrum disorder. Results The results are a model named: "Filters in the coping process of people with a diagnosis of schizophrenia spectrum disorder who have inadequate social support." The type of coping strategies used evolves over time and in accordance with the filters. The consequence of the process is "surface coping." Discussion The coping potential of people with schizophrenia spectrum disorder is affected by environmental factors as well as factors inherent to the disorder itself. The filter model provides a holistic perspective, as opposed to merely focusing on behaviours. Implication for practice The findings of this study could improve nursing interventions through a better understanding of impediments to coping: what they are, how they arise and the nature of their effects.

[The Virtual Emotional Drowning Theory: a Grounded Theory on Information and Communication Technologies (ICT) Help-Seeking Process of Adolescents at Risk of Suicide]. / La théorie de la noyade émotive virtuelle : une théorisation ancrée sur le processus de recherche d'aide d'adolescents à risque de suicide.

The use of Information and Communication Technologies (ICT) for help-seeking is becoming more and more common for adolescents at risk of suicide. Objectives The aim of this current study was to better understand the help-seeking process of adolescents at risk for suicide. Methods A grounded theory methodology was used to describe the experience of adolescents at risk of suicide and gain a deeper understanding of their ICT help-seeking process. Data was collected through semi-structured interviews, an ICT help-seeking questionnaire and live observations of ICT help-seeking strategies by the adolescents of this study. Theoretical saturation was reached with a total of 15 adolescents, aged 13 to 17, at risk of suicide. Results The grounded theory that emerged gravitated towards the fact that adolescents chose to virtually deal with emotional drowning. A specific context allowed this central category to emerge and included the adolescents' state, their personal triggers, their social environment as well as their desire to use ICT. The ICT strategies used by the adolescents to deal with their emotional drowning were to distract themselves, to get informed, to reveal themselves or to help others. Adolescents in this study used different ways to distract themselves with ICT. This included reading texts, watching online videos, listening to music and playing games. They also increased their literacy by informing themselves on suicide and mental health problems. However, many adolescents also searched for ways to help them commit suicide. Although most of the results were suicide prevention related, the keywords used by the adolescents remain preoccupying. Revealing their thoughts and their feelings about their emotional state seemed to be easier through ICT. They sometimes chose to reveal themselves anonymously but most of the time, they revealed themselves to use ICT to friends they already had in real life. Also, helping friends through ICT seemed to be very rewarding and helpful to the adolescents of our study even when they were in a state of emotional drowning. These different strategies to virtually deal with their emotional drowning hindered many different consequences which were to grow emotionally, to get help, to get temporary relief, to stay indifferent, to worsen their suicidal thoughts or to attempt suicide. Conclusion Although some negative consequences of ICT emerge from this study, a great deal of the consequences was positive and helpful for these adolescents. Overall, this study shows that ICT offer great opportunities for adolescent suicide prevention. Implications for practice, training and research are further discussed.

[Self disclosure among men living with schizophrenia] / Le dévoilement de soi chez les hommes vivant avec la schizophrénie.

Self-disclosure of patients with schizophrenia is crucial for the establishment of the therapeutic relationship and to provide safe and quality care. However, it is reasonable to think that these patients do not fully reveal. But if the disclosure is bound to need help and has the potential to reduce stigma, it also exposes the person to negative consequences. The purpose of this study is to study aims to describe how people living with schizophrenia disclose themselves. These are results from a larger research that used grounded theory. Measures of perceived social support, in behavior and symptoms, and psychiatric comorbidities were also collected. The results describe the unveiling of the modulation process, consisting of four subcategories : be invited to speak authentically, have the ability to disclose, expect to actually be helped and fear of stigma. The results highlight the features of the self-disclosure of people with schizophrenia. Health professionals should pay attention to these elements when they question the quality of the self-unveiling of patients with schizophrenia.

Integrated Primary Care Teams (IPCT) pilot project in Quebec: a protocol paper.

INTRODUCTION: The overall aim of this project is to help develop knowledge about primary care delivery models likely to improve the accessibility, quality and efficiency of care. Operationally, this objective will be achieved through supporting and evaluating 8 primary care team pilot sites that rely on an expanded nursing role within a more intensive team-based, interdisciplinary setting. METHODS AND ANALYSIS: The first research component is aimed at supporting the development and implementation of the pilot projects, and is divided into 2 parts. The first part is a logical analysis based on interpreting available scientific data to understand the causal processes by which the objectives of the intervention being studied may be achieved. The second part is a developmental evaluation to support teams in the field in a participatory manner and thereby learn from experience. Operationally, the developmental evaluation phase mainly involves semistructured interviews. The second component of the project design focuses on evaluating pilot project results and assessing their costs. This component is in turn made up of 2 parts. Part 1 is a pre-and-post survey of patients receiving the intervention care to analyse their care experience. In part 2, each patient enrolled in part 1 (around 4000 patients) will be matched with 2 patients followed within a traditional primary care model, so that a comparative analysis of the accessibility, quality and efficiency of the intervention can be performed. The cohorts formed in this way will be followed longitudinally for 4 years. ETHICS AND DISSEMINATION: The project, as well as all consent forms and research tools, have been accepted by 2 health sciences research ethics committees. The procedures used will conform to best practices regarding the anonymity of patients.

[Looking for help on the Internet by adolescents with suicidal thoughts: a concept analysis]. / La recherche d'aide sur Internet chez des adolescents ayant des idées suicidaires: une analyse de concept.

The help-seeking concept is largely used in the healthcare system and seems relatively well understood by healthcare professionals even though no consensus on this concept has yet been reached. More specifically, the Internet help-seeking concept by adolescents with suicidal thoughts has yet to be explored. To clarify this concept and eventually develop tools for future research in nursing, a concept analysis using the Walker and Avant method was conducted. Three main help-seeking attributes were identified as a result of the analysis: problem-oriented, intentional action and use of an external mean. The antecedents that precede the concept are: problem recognition and perception influenced by beliefs, desired relief, help-source selection and decision to act. The consequents that follow help-seeking are relef, maintenance or exacerbation of the problem. Many empirical referents are identified but none seem to evaluate or conceptually define the attributes of the concept. Finally, a deeper meaning of Internet help-seeking by adolescents with suicidal thoughts is reached by this concept analysis and further research and practice recommendations are given.

Feasibility and acceptability of patient partnership to improve access to primary care for the physical health of patients with severe mental illnesses: an interactive guide.

INTRODUCTION: Even in countries with universal healthcare systems, excess mortality rates due to physical chronic diseases in patients also suffering from serious mental illness like schizophrenia is such that their life expectancy could be lessened by up to 20 years. The possible explanations for this disparity include: unhealthy habits (i.e. smoking; lack of exercise); side-effects of psychotropic medication; delays in the detection or initial presentation leading to a more advanced disease at diagnosis; and inequity of access to services. The main objective of this paper is to explore the feasibility and acceptability of patient partnership for developing an interactive guide to improve access to primary care providers for chronic diseases management and health promotion among patients with severe mental illnesses. METHODS: A participatory action research design was used to engage patients with mental illness as full research partners for a strategy for patient-oriented research in primary care for persons with schizophrenia who also have chronic physical illnesses. This strategy was also developed in partnership with a health and social services centre responsible for the health of the population of a territory with about 100,000 inhabitants in East-end Montreal, Canada. A new interactive guide was developed by patient research partners and used by 146 participating patients with serious mental illness who live on this territory, for them to be better prepared for their medical appointment with a General Practitioner by becoming more aware of their own physical condition. RESULTS: Patient research partners produced a series of 33 short videos depicting signs and symptoms of common chronic diseases and risk factors for the leading causes of mortality and study participants were able to complete the corresponding 33-item questionnaire on an electronic touch screen tablet. What proved to be most relevant in terms of interactivity was the dynamic that has developed among the study participants during the small group learning sessions, a training technique designed for healthcare professionals that was adapted for this project for, and with patient partners. CONCLUSION: This research has shown the feasibility and acceptability of patient partnership and patient-oriented research approaches to the R&D process of a new medical tool and intervention for patients with serious mental illness, and its acceptability for addressing inequity of this disadvantaged population in terms of access to primary care providers.

Attempted Suicide Among Students and Young Adults in Montreal, Quebec, Canada: A Retrospective Cross-Sectional Study of Hospitalized and Nonhospitalized Suicide Attempts Based on Chart Review.

OBJECTIVE: We conducted a chart review to identify postsecondary students and nonstudents in the same age range who presented to the emergency department following a suicide attempt to (1) compare demographic characteristics and suicide risk factors and (2) determine factors associated with more serious attempts requiring hospitalizations. METHOD: The study was conducted in 1 tertiary trauma hospital and 1 community hospital affiliated with McGill University, Montreal, Quebec, Canada, between January 1, 2009, and March 31, 2010. Charts of patients with potential suicide attempts were identified from medical records using ICD-10 codes that indicated traumatic injury, intentional self-harm, poisoning, and psychiatric or perception/cognition disorders and from the emergency department triage file using keywords that indicated suicidality or self-harm at presentation. RESULTS: In multivariable logistic regression models (odds ratio, 95% CI), students were younger (per 5-year increase: 0.22, 0.12-0.41), less likely to be born in Canada (0.17, 0.06-0.44), and more likely to use less violent methods (laceration, poisoning, other, multiple methods) versus more violent methods (collision, jump, fire burns, firearm, hanging) in their attempt. Fewer students had a history of substance abuse (0.12, 0.02-0.94) but were not different from nonstudents on history of other mental disorders. Less students attempted suicide in the winter/spring (January-April) versus fall (September-December) semester (0.32, 0.11-0.91). Students who attempted suicide were more likely to have family/social support. Those who attempted suicide in the previous year were more likely to require hospitalization for their current suicide attempt. CONCLUSIONS: Knowledge of specific factors associated with suicide attempts in young people can help inform and guide suicide prevention efforts in both academic and community settings. Specific to the findings of this study regarding the method of suicide attempt used, for example, limiting access to dangerous substances or large quantities of medications may help prevent or reduce suicide attempts in this population.

[The role of families in the Quebec mental health system]. / Le rôle des familles au sein du système de santé mentale au Québec.

Purpose. This paper aims to summarize the current situation regarding the role of families of persons with mental disorders within the mental health system in Quebec.Methods. We made a research in the most recent and pertinent papers or books regarding: 1) the history of the family involvement in the mental health system in Quebec; 2) the present situation of these families and the models that we can see and 3) identify in recent governmental or research documents recommendations regarding a greater empowerment of the families in the mental health system.Results. The research provides a historical perspective to the roles occupied by families. First the family was described as a causal agent; the work of the psychoanalyst Freud described the family unit as a source of conflicts in the areas of affect and sexual dynamics, and which results in the appearance of psychiatric symptoms. Later, this view of a causal agent came both from the point of view of genetic and from expressed emotions. In the 70's new perspectives such as general systems theory (von Bertalanffy, 1968), described the family as responsive to mental disorder of one of its members rather than a responsible agent. With the deinstitutionalization movement, the family was perceived as a source of solutions for persons with mental illness, but also as persons who can live some burden. This subject became well described and a several studies reported about adverse effects of caring for a person with mental disorder on the health, well-being and feeling of caregiver burden. In the 90's, some government action plans called for the relationship between the family and the health system as a partnership. Also, families want to be involved in decisions about care and to be informed about the diagnosis and treatment options. ( Lefley et Wasow, 1993)A new model developed by FFAPAMM that identifies three main roles enables to contextualize the current role in the current system. This model, called CAP lists and describes three roles of families that, if they are dependent on the past, continue to mingle in our time. These roles are:Accompanist: the role imposed by being near a person with mental illness (Fradet, 2012). As an accompanist, the family needs to establish relationships with health professionals. Accompanists want to be considered by stakeholders and be respected in their desire to share information and participate in decisions.Client: this is the role that derives from the accompanist when the caregiver receives care services for its psychological or physical problems related to the fact support a sick person.Partner: it is relative to the involvement (or not) the role of family members in the organization of care. It is a role of participation and decision-making. In this context, we also speak of participation in the consultation mechanisms.Recommendations from a Quebec research project and a report of the Commission on Mental Health of Canada will consider a future where the needs and aspirations of families will be taken into account in mental health general services, short term health care, community mental health services. There are also some guidelines regarding education for professionals about the needs of families and about changing politics.Conclusion. There exists in all associations of families of person with mental disorders, training on topics such as how to behave towards different mental disorders or aggressiveness near reached. A project of the Douglas Institute has hired a family member to the emergency room to help families better manage this often difficult time and to facilitate communication with stakeholders. Another project called "Learning to come closer without aggression" has helped more than 200 family members undergo training inspired by the Omega approach, which helps them better manage their own behavior in situations of aggression with their loved one.

[Role of families of homeless persons with mental disorders : retrospective and prospective view of relationships]. / Le rôle des familles de personnes en situation d'itinérance et souffrant de troubles mentaux : un regard rétrospectif et prospectif des liens.

This paper explores the experience of families supporting a homeless relative with mental illness. The authors investigate the types of support offered by families; they also examine the relational and personal dimensions which can support a redefining of the role and consequently a modulation of the level of support. Using a qualitative research, semi-structured interviews were realized with 14 family members. The results indicate that housing and the financial support are the types of support most frequently stopped while the emotional and the social support tend to be pursued. The control in the relation, the emotionalism and the perception of future appear as important element for the initiation of a role redefining process.

The experience of seclusion and restraint in psychiatric settings: perspectives of patients.

Many studies report that the use of seclusion and restraint (SR) is experienced negatively by patients who experience feelings of shame, helplessness, and humiliation, and may relive previous trauma events. Since 2000, in Québec, exceptional measures like SR have been framed by a protocol. This protocol provides health care teams with guidelines for relieving, containing, and reducing the suffering caused by SR. We have no knowledge, however, about the views of patients regarding application of the protocol. This study aims to understand the perception of patients regarding application of the SR protocol. For this purpose, a questionnaire was presented to patients (n = 50) who experienced an episode of SR in a psychiatric hospital in Canada. Results show that patients had a nuanced perception of SR: Some felt that SR was a helpful measure, while others felt that SR was not a helpful measure. Patients tended to agree with statements related to the comfort and safety of seclusion rooms and the meeting of their physical needs. Regarding support, they suggested relational, drug, and environmental interventions to prevent seclusion. Finally, nearly all patients perceived that the health care team did not follow-up with the patients after the experience; such follow-up is essential for reconstructing a sometimes confusing event.

Families' and decision makers' experiences with mental health care reform: the challenge of collaboration.

Family-driven collaboration is fundamental to developing a new model of health care and eliminating fragmented services in mental health. The province of Québec (Canada) recently undertook major transformations of its mental health care system. These transformations represent an opportunity to improve collaboration between families and health care practitioners and to understand which factors facilitate this collaboration. This article describes how families and decision makers perceive collaboration in the context of a major transformation of mental health services and identifies the factors that facilitate and hinder family collaboration.

[The analysis of a mobile mental health outreach team activity: from psychiatric emergencies on the street to practice of hospitalization at home for homeless people]. / Analyse de l'activité d'une équipe mobile psychiatrie-précarité (EMPP) : des urgences médicopsychiatriques dans la rue à la pratique d'hospitalisation à domicile pour des personnes sans domicile.

CONTEXT AND OBJECTIVE: Since their creation in 2005 in France, mobile mental health outreach teams (EMPP) have been working to improve the health of the homeless who, for 30 to 50% of them, present severe mental disorders. Their missions are defined by ministerial circular's specifications. Few studies have been undertaken in France to analyze the practices of these teams' professionals, nor the characteristics of the populations with whom they are involved. The EMPP described in this paper had in 2010 a greater staff than other French EMPPs. It has 15 full-time staff, including four doctors (two psychiatrists, one GP, one house physician), two nurses, two educators, one social worker, three peer-workers, one secretary and two coordinators. The article analyzes the way of support developed within the range of EMPP's missions defined by the ministerial circular. METHODS: Descriptive statistical analysis was carried out using standardized data from four different sources (round sheet, record of activity, record of hospitalization, housing information, interviews conducted by medical and social professionals with patients). Another source of data consists of records describing the operation of the team (reference framework) and annual activities (annual report). RESULTS: The method of care was developed based on a street working, involving a full medical and its relationship with the hospital and a place to live in a semi-community context. The Mobile Mental Health Outreach team documented 318 rounds in 2010, describing 666 contacts among whom 87.9% were followed regularly thereafter. It focuses to a target population. The team actively followed 198 people including 161 for whom a psychiatric diagnosis was done: 48.5% of the patients followed presented schizophrenic-type disorders, 21.8% bipolar disorders and other mood-linked problems, 13% behavioral disorders and 6.2% substance-use disorders. A percentage of 44.9 presented with a physical disease. Among the 89 hospitalizations, 86.5% were motivated by psychiatric disorders and 43% were forced. In about one third of the cases, hospitalizations were motivated by a double indication - psychiatric and physical - and in 13.5% for only a physical indication. Thirty people of the actively followed people had stayed in a halfway house as an alternative to hospitalization, restoring a continuity of care and allowing to resolve social problems that had until then been hopeless. PERSPECTIVES: The strategies developed by this Mobile Health Outreach Team ensure local community medical, psychiatric and social care for "hard to reach" people. The results confirm the interest of the link between the street work, the hospital and the halfway home, both as a living facility and an alternative to hospitalization. They suggest the importance of a critical minimum size for these EMPP that allows them a street work with doctors providing guidance. The presence of a GP is another welcome development because of the severity and the entanglement of somatic and psychiatric problems of these populations.

Implementation of diagnosis-related mental health programs: impact on health care providers.

Mental health services are in the midst of change in different countries. In Quebec (Canada), the government has adopted a Mental Health Action Plan (2005-2010). In this context, 2 psychiatric institutions have developed and implemented a mental health services organization model based on diagnosis-related mental health programs and support for frontline services. This article presents the impact on health care providers of implementation of diagnosis-related mental health programs in the context of transformation of mental health services.

Contribution of the psychosocial work environment to psychological distress among health care professionals before and during a major organizational change.

The aim of this study was to investigate the relationships between 4 dimensions of the psychosocial work environment (psychological demands, decision latitude, social support, and effort-reward) among health care professionals as well as their psychological distress during a reorganization process. A correlational descriptive design was used for this quantitative study. A total of 159 health care professionals completed the questionnaire at T1, and 141 at T2. First, before the work reorganization, effort-reward imbalance was the sole variable of the psychological work environment that significantly predicted psychological distress. Second, the high overall level of psychological distress increased during the process of organizational change (from T1 to T2). Finally, effort-reward imbalance, high psychological demands, and low decision latitude were all significant predictors of psychological distress at T2, during the organizational change. In conclusion, to reduce the expected negative outcomes of restructuring on health care practitioners, managers could increase the number of opportunities for rewards, carefully explain the demands, and clarify the tasks to be performed by each of the employees to reduce their psychological burden and increase their perceptions of autonomy.

Health and mental health care utilization by clients of resources for homeless persons in quebec city and montreal, Canada: a 5-year follow-up study.

The objective of this cohort study is to describe the service utilization by clients of homeless resources in Quebec and Montreal (Canada) over a 5-year period. Participants (N = 426) were recruited from a survey conducted in 1999 about clients' utilization of resources intended for homeless people in Montreal and Quebec. Data analyzed in this study were also drawn from three administrative databanks managed by the Quebec health care system. Results revealed that: (1) in general, mental health services are less used than physical health services; (2) generally, women, older persons, nonhomeless persons, and persons with mental health problems utilized proportionately more health services; and (3) participants involved in this study tend to continue using services over years in a system where health services are free. These findings are discussed in terms of long-term service utilization by clients of homeless resources.

Workplace violence reported by Canadian nurses.

The purpose of this study was to determine the prevalence, origins, and forms of workplace violence reported by nurses working in acute-care settings in the Canadian province of Quebec. The Quebec health-care system is currently undergoing a shortage of qualified nurses that has resulted in an oppressive work environment marked by violence towards nurses.A descriptive study design was used with a sample of 181 nurses (out of a possible 300).The data, collected in 2003 using a French translation of the Workplace Violence Events Questionnaire, show that 86.5% of the nurses were victims of violent incidents on more than 1 occasion.The nature of the abuse was physical (10.6%), psychological (86.4%), or sexual (30.7%), inflicted by a colleague (65.9%), a superior (59.6%), or a physician (59.1%). Nurses should be made aware of the prevalence of workplace violence. Preventive measures are urgently needed for the well-being of the nursing profession.

[Mixed methods: promising strategies for the evaluation of nursing interventions]. / Les méthodes mixtes: stratégies prometteuses pour l'évaluation des interventions infirmières.

Based on a survey of the literature in human and nursing sciences and illustrated with concrete research examples, we will identify promising research directions for mixed-methods studies and present strategies for applying this type of research design to the evaluation of nursing interventions. This article provides three examples of mixed-methods design that utilize schematic representation about evaluation of nursing interventions. Based on examples, the issues discussed are: (1) sufficient significance for research program to invest the required human and material resources, (2) reason for using qualitative and quantitative data simultaneously or sequentially, (3) integration of qualitative and quantitative data when the participants are from different target populations; (4) presentation of the findings.

[Cross training program in Montréal's south west: best practices and training in a context of continuum of services in mental health care and addiction treatment]. / Meilleures pratiques et formation dans le contexte du continuum des services en santé mentale et en toxicomanie : le programme de formation croisée du sud-ouest de Montréal.

This article presents the cross training program in Montreal's south-west. The authors underline that the context of post-deinstitutionalization and mental health service integration impose new roles to professionals who work within these different networks of services. Cross training thus appears as a model that is particularly adapted to their needs in order to optimize their interventions. The model is presented with a review of the most recent studies and is illustrated with the cross training program, a model developed by the networks of mental health care and addiction treatment in Montreal's south-west. The program's applications are examined for other networks of care and services.