Assessing professionalism in mental health clinicians: development and validation of a situational judgement test.

BACKGROUND: Situational judgement test (SJT) scores have been observed to predict actual workplace performance. They are commonly used to assess non-academic attributes as part of selection into many healthcare roles. However, no validated SJT yet exists for recruiting into mental health services. AIMS: To develop and validate an SJT that can evaluate procedural knowledge of professionalism in applicants to clinical roles in mental health services. METHOD: SJT item content was generated through interviews and focus groups with 56 professionals, patients and carers related to a large National Health Service mental health trust in England. These subject matter experts informed the content of the final items for the SJT. The SJT was completed by 73 registered nurses and 36 allied health professionals (AHPs). The primary outcome measure was supervisor ratings of professionalism and effectiveness on a relative percentile rating scale and was present for 69 of the participating nurses and AHPs. Personality assessment scores were reported as a secondary outcome. RESULTS: SJT scores statistically significantly predicted ratings of professionalism (ß = 0.31, P = 0.01) and effectiveness (ß = 0.32, P = 0.01). The scores demonstrated statistically significant incremental predictive validity over the personality assessment scores for predicting supervisor ratings of professionalism (ß = 0.26, P = 0.03). CONCLUSIONS: These findings demonstrate that a carefully designed SJT can validly assess important personal attributes in clinicians working in mental health services. Such assessments are likely to represent evidence based, cost-effective tools that can support values-based recruitment to mental health service roles.

Great expectations: views and perceptions of professionalism amongst mental health services staff, patients and carers.

BACKGROUND: Numerous studies have explored the concept of 'professionalism' in medicine, yet little attention has been paid to the concept in a mental health services context. AIMS: This study sought to determine how the lived experience of patients, carers and healthcare professionals in mental health services align with medically defined, generic, professionalism standards. METHOD: Interviews and focus groups were conducted with patients, carers, nurses, occupational therapists, psychiatrists and psychologists. A framework analysis approach was used to analyse the data, based on the 'Improving Selection to the Foundation Programmes' Professional Attributes Framework. RESULTS: Fifty-six individuals participated. Data aligned to all nine attributes of the Professional Attributes Framework, however the expectations within each attribute varied from that originally cited. A tenth attribute was devised during the process of analysis; Working with Carers. This attribute acknowledges the need to liaise with, and support carers in mental health services. Situational examples included both online and offline behaviours and the topic of 'black humour' emerged. CONCLUSIONS: Compared to a conventional medical definition of professionalism, additional themes and differing emphases were observed for mental health and learning disability services. These findings should be used to inform the teaching and evaluation of professionalism, especially for staff pursuing mental health service careers.

Impact of family practice continuity of care on unplanned hospital use for people with serious mental illness.

OBJECTIVE: To investigate whether continuity of care in family practice reduces unplanned hospital use for people with serious mental illness (SMI). DATA SOURCES: Linked administrative data on family practice and hospital utilization by people with SMI in England, 2007-2014. STUDY DESIGN: This observational cohort study used discrete-time survival analysis to investigate the relationship between continuity of care in family practice and unplanned hospital use: emergency department (ED) presentations, and unplanned admissions for SMI and ambulatory care-sensitive conditions (ACSC). The analysis distinguishes between relational continuity and management/ informational continuity (as captured by care plans) and accounts for unobserved confounding by examining deviation from long-term averages. DATA COLLECTION/EXTRACTION METHODS: Individual-level family practice administrative data linked to hospital administrative data. PRINCIPAL FINDINGS: Higher relational continuity was associated with 8-11 percent lower risk of ED presentation and 23-27 percent lower risk of ACSC admissions. Care plans were associated with 29 percent lower risk of ED presentation, 39 percent lower risk of SMI admissions, and 32 percent lower risk of ACSC admissions. CONCLUSIONS: Family practice continuity of care can reduce unplanned hospital use for physical and mental health of people with SMI.

Association Between Antipsychotic Polypharmacy and Outcomes for People With Serious Mental Illness in England.

OBJECTIVE: Although U.K. and international guidelines recommend monotherapy, antipsychotic polypharmacy among patients with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. Therefore, the authors estimated the effectiveness of antipsychotic polypharmacy relative to monotherapy in terms of health care utilization and mortality. METHODS: Primary care data from Clinical Practice Research Datalink, hospital data from Hospital Episode Statistics, and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England from 2000 to 2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to first occurrence of each of three outcomes: unplanned hospital admissions (all cause), emergency department (ED) visits, and mortality. RESULTS: Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of unplanned hospital admission (hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.98-1.32), ED visit (HR=0.95; 95% CI=0.80-1.14), or death (HR=1.02; 95% CI=0.76-1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced hazard of unplanned admissions to the hospital and ED visits, but it had no effect on mortality. CONCLUSIONS: The study results support current guidelines for antipsychotic monotherapy in routine clinical practice. However, they also suggest that when clinicians have deemed antipsychotic polypharmacy necessary, health care utilization and mortality are not affected.

Defining professionalism for mental health services: a rapid systematic review.

Background: Efforts have been made to define professionalism across the professions, yet little attention has been paid to the concept in mental health services, where patients' needs differ to that in other healthcare specialties. Aims: To derive a definition of professionalism for mental health services using the existing literature. Method: A rapid, systematic review was conducted to identify empirical and non-empirical records that described professionalism in a mental health service context from 2006 to 2017. Studies were synthesised narratively using thematic analysis. Results: Seventy records were included in the review. Professionalism was described on two levels; at a societal level, a dynamic social contract between professions and society, and; at an individual level, having intrapersonal, interpersonal, and working professionalism. Utilising emerging themes, an operationalised definition of professionalism, suitable for a mental health service context was derived. Conclusions: Within mental health services, emphasis is placed on the interpersonal aspects of practice such as communication skills, maintaining boundaries and humanity. Themes relating to the vulnerability of patients and the challenge of supporting autonomy and choice whilst maintaining safety and acting in a client's best interest are also evident. 'Practical wisdom' and a flexible approach to working are needed to manage these challenging situations.

Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England.

OBJECTIVE: To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI). DESIGN, SETTING, PARTICIPANTS: Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database. OUTCOMES AND ANALYSIS: Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC). RESULTS: Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews. CONCLUSIONS: Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.

Identifying primary care quality indicators for people with serious mental illness: a systematic review.

BACKGROUND: Serious mental illness (SMI) - which comprises long-term conditions such as schizophrenia, bipolar disorder, and other psychoses - has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care. AIM: The objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care. DESIGN AND SETTING: A systematic literature review, combined with a search of quality indicator databases and guidelines. METHOD: The authors assessed whether indicators could be measured from routine data and the quality of the evidence. RESULTS: Out of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence. CONCLUSION: With appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes.

Does the quality and outcomes framework reduce psychiatric admissions in people with serious mental illness? A regression analysis.

BACKGROUND: The Quality and Outcomes Framework (QOF) incentivises general practices in England to provide proactive care for people with serious mental illness (SMI) including schizophrenia, bipolar disorder and other psychoses. Better proactive primary care may reduce the risk of psychiatric admissions to hospital, but this has never been tested empirically. METHODS: The QOF data set included 8234 general practices in England from 2006/2007 to 2010/2011. Rates of hospital admissions with primary diagnoses of SMI or bipolar disorder were estimated from national routine hospital data and aggregated to practice level. Poisson regression was used to analyse associations. RESULTS: Practices with higher achievement on the annual review for SMI patients (MH9), or that performed better on either of the two lithium indicators for bipolar patients (MH4 or MH5), had more psychiatric admissions. An additional 1% in achievement rates for MH9 was associated with an average increase in the annual practice admission rate of 0.19% (95% CI 0.10% to 0.28%) or 0.007 patients (95% CI 0.003 to 0.01). CONCLUSIONS: The positive association was contrary to expectation, but there are several possible explanations: better quality primary care may identify unmet need for secondary care; higher QOF achievement may not prevent the need for secondary care; individuals may receive their QOF checks postdischarge rather than prior to admission; individuals with more severe SMI may be more likely to be registered with practices with better QOF performance; and QOF may be a poor measure of the quality of care for people with SMI.