Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey.

BACKGROUND: Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption. METHODS: Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption. RESULTS: The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients' treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care. CONCLUSIONS: HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient's preferences in the care process - preferably before starting treatment through discussions in a multidisciplinary meeting.

[Homeless persons residing in shelters in the county of Funen I. Psychosocial characteristics and need of treatment]. / Hjemløse på forsorgshjem og herberger i Fyns Amt I. Psykosocial karakteristik og behandlingsbehov.

In the County of Funen (population 460,000) 120 homeless people resided in shelters for homeless people during week 49, 1996. Of these homeless persons, 94 (or 78%) were examined using ICD-10 and the Addiction Severity Index. Ninety percent were men, 90% were aged 20-59 years, 98% were unmarried or separated/divorced. Seventy-one percent had lived alone during the past three years, only 2% were employed, and sources of income for 83% were public assistance or disability pensions. The population of homeless people was divided into three groups: 1) Psychoses were found in 13 cases or 14%--schizophrenia (4%), paranoid psychosis (4%) and affective disorder (5%). About 2/3 had double disorder, psychosis plus substance abuse. 2) Sixty-four or 68% were non-psychotic homeless people, who had alcohol/substance abuse (53 or 83%) and/or personality disorder (57 or 89%). 3) Seventeen or 18% had no mental illness. About 60% had been sentenced to prison at least once. About 20% needed psychiatric treatment.

[Homeless persons residing in shelters in the county of Funen II. Comparison between 1990 and 1996 and occurrence of mental disease]. / Hjemløse på forsorgshjem og herberger i Fyns Amt II. Sammenligning mellem 1990 og 1996 af forekomsten af psykisk lidelse.

The question has been raised whether the change from hospital to community psychiatry is accompanied by an increasing number of the mentally ill in institutions for homeless people. During week 49, 1996, the residents in institutions for homeless people in the County of Funen were interviewed and diagnosed according to ICD-8, and the results were compared with a similar study from week 47, 1990. The prevalence of psychoses was 11% in 1990 and 14% in 1996. This difference was not significant. Significantly fewer psychotic homeless people were treated for their psychotic disorders in 1996 compared with 1990. The prevalence of alcoholics had fallen by 35%, while the prevalence of narcotics and cannabis addicts had risen by 78% and 110%, respectively. These changes were statistically significant. There was still a high prevalence of personality disorders, 70% in 1990 and 60% in 1996. Even though the deinstitutionalization of the psychiatric service has not been accompanied by more psychotic patients in institutions for the homeless, the clientele is still heavily strained with psychosis, personality disorder and substance abuse.

[Differences between male and female alcoholics and differences in their need of treatment]. / Forskelle mellem kvindelige og mandlige alkoholmisbrugere og forskelle i deres behandlingsbehov.

The present study covers 375 consecutive patients referred to the three outpatient clinics at the Psychiatric Department of Odense University Hospital from November 1995 to February 1997. The aim of the study was to describe differences in problem profiles for men and women. All patients were assessed by means of the Addiction Severity Index at admission. All patients needed treatment for alcohol problems. Significantly more female alcoholics, however, had problems with mental health, physical health, drug use and family/social life. More men than women had legal problems. Almost half of the women had previously attempted to commit suicide, and almost one third of the women suffered from anxiety disorder at the time of admission. Significantly more women than men had partner who also had an alcohol problem.

[Factors related to suicidal behavior among alcoholics]. / Faktorer relateret til suicidal adfaerd blandt alkoholmisbrugere.

Of 181 alcoholics who consecutively sought treatment as out- or inpatients, 68 (37.6%) had attempted suicide at least once. Compared with non-attempters, the suicide attempters were significantly more likely to be female, have had a chaotic upbringing and to have known suicide attempts in the family and social circle. Significantly more attempters suffered from depressive disorder, feelings of hopelessness, anxiety attacks, agoraphobia, substance abuse or cluster B personality disorders (dissocial, impulsive, borderline, and histrionic). Also significantly more suicide attempters had committed crimes and received early pension. Assessment of coping showed that suicide attempters had a significantly lower tendency to make plans or to make the best of a stressful situation by growing from it. They were significantly more likely to show mental disengagement, to resort to denial and drink alcohol or take drugs when faced with stressful events or difficulties. When evaluated on the Addiction Severity Index Scale, the suicide attempters were found to have a significantly greater need of treatment.

[The staff's experience of patient violence in a psychiatric department]. / Personalets oplevelse af patientvold på en psykiatrisk afdeling.

Three hundred and thirty individuals (80% of the total staff members at a Department of Psychiatry) completed a questionnaire concerning their exposure to patient violence. It was found that over 90% of physicians, nurses and nursing aides had been subjected to patient violence at least once during the entire course of their employment in departments of psychiatry. The following percentages were found for incidents of patients violence occurring during a one year period towards staff while employed in departments of psychiatry: residents (17%), nurses (36%), and nursing aides (52%). The highest frequency was found for nursing staff working in closed wards (75%). Length of employment, and thereby the staff's experience, was not related to exposure to patient violence. Neither sex nor age of the nursing staff were significantly associated with their exposure to patient violence. About 1/3 of the nurses and nursing aides had considered changing their job because of patient violence.

[Psychiatric diseases among the homeless in Funen County]. / Psykiatriske lidelser blandt hjemløse i Fyns Amt.

The purpose of the study was to investigate whether deinstitutionalization of psychiatric patients had produced a clientele of homeless mentally ill people which is not treated. During week 47, 1990, 94 of the 129 residents 73%) in the institutions for homeless people in the County of Funen (population 459,000) were examined for mental illness by a psychiatrist. Diagnoses were made using the ICD-8 classification. Social data were recorded. Eighty-nine per cent were men, 59% were aged 30-49 years, 93% were single, and source of incomes for 80% were public assistance or disability pensions. More than half had been sentenced for crime at least once. The majority suffered from severe psychosocial strain. In 91% a psychiatric diagnosis was established, the most frequent being alcoholism (73%) and personality or character disorder (70%). Psychoses were found in 10 cases or 11%. About 29% required psychiatric treatment. The conclusion was that deinstitutionalization in the County of Funen had not resulted in influx of psychotic persons to institutions for the homeless people.

[The circumstances of life and need for social measures of patients with prolonged psychiatric illness]. / Langtidssyge psykiatriske patienters levevilkår og behov for sociale foranstaltninger.

The circumstances of life and the need for social support were investigated in 142 patients with prolonged psychiatric illness who sought help consecutively in the psychiatric casualty department or who were referred to the psychiatric department of Odense Hospital during the period 11 Sep. 1989-31 Dec. 1989. 80% of these were psychotic and 20% were borderline psychotic. Approximately 90% were young adults (20-49 years). Schizophrenic men predominated. More than 40% of all the patients had some form of addiction as a contributory diagnosis and 71% of the patients with borderline psychoses were addicts. Approximately 3/4 of the patients lived alone in flats. The level of occupational training was low as compared with the remainder of the population. The majority received early pensions. The majority lived in social isolation from the remainder of the community. Only a single patient had no fixed abode but suitable forms of residence where social support could be given were insufficient. Similarly, the requirements for possible employment and leisure activities were great.

[Violent patients in a psychiatric outpatient department]. / Voldelige patienter på psykiatrisk skadestue.

During the period 23.11.1987-22.11.1989, a total of 7,906 patients attended the psychiatric outpatient department and observation section on 12,469 occasions. Sixty patients (0.8%) behaved violently on 85 occasions. None of these episodes of violence resulted in injuries to persons requiring medical attention. 90% of the violent patients were men and 70% were in the age group 20-39 years. Approximately 1/5 were psychotic and, of these, approximately half suffered from schizophrenia. Comparison with the non-violent patient revealed that the probability of violence was greater if the patient was a man under the influence of alcohol and who had the diagnoses of narcomania, drug abuse or personality disorders. Significantly fewer violent patients were admitted than non-violent patients. Over 80% of the violent patients had previously been admitted to psychiatric departments. Approximately 60% had behaved violently on previous consultations with the psychiatric outpatient department.

[Violent behavior among hospitalized psychiatric patients. 1. Occurrence and psychopathology]. / Voldelig adfaerd blandt indlagte psykiatriske patienter. 1. Forekomst og psykopatologi.

The majority of psychiatric patients are not violent during hospitalisation. A minority behave violently during hospitalisation on repeated occasions but violent episodes are mainly concerned and these do not result in corporeal injuries. Gross violence rarely occurs. Violence involves the caring staff most frequently and, more rarely, fellow patients. The patients who are most frequently violent are the most severely ill and untreated psychotic patients. The commonest diagnosis among the violent patients is schizophrenia. Younger patients are often violent. No sex differences exist for violent behaviour. Manic patients are rarely violent and depressive illness is negatively correlated with violence. Approximately 1/5 of the demented patients show violent behaviour. The review demonstrates many methodological deficiencies in the investigations mentioned and presents recommendations concerning the design of investigations in future investigations.

[Violent behavior among hospitalized psychiatric patients. 2. The significance of the functioning of the department and the reactions of the staff]. / Voldelig adfaerd blandt indlagte psykiatriske patienter. 2. Betydningen af afdelingens funktion og personalets reaktioner.

Violence is commonest in emergency and closed departments. Lack of structure in the department and inactivity together with an authoritarian staff attitude may increase the frequencies of violent episodes. Too much therapeutic activity may also cause violence in the department. In order to reduce the frequency of episodes of violence, the staff must be adequate in number. Good contact with the patients may have a preventative effect on violence. The experience of the care staff in the treatment of psychiatric patients is of considerable significance. Massive staff changes with appointment of less experienced care staff and many temporary staff members in the department may increase the extent of violence. Training of the staff in the technique of controlling aggression may improve their ability to cope with violent situations. The effect of staff training may depend upon the content of the training programme. Medical assistance may increase the staff capacity to manage difficult situations such as violent episodes. Leaders have considerable influence on the factors which can reduce the extent of violence. Previous investigations show many methodological defects and new investigations are necessary.

[Attempted suicide and depression]. / Selvmordsforsøg og depression.

The frequency of depressive illness was investigated in 195 patients who had been referred consecutively after attempted suicide during the period 15. February 1989-15, October 1989. A total of 130 of these patients were admitted to hospital while the remainder were treated in the psychiatric emergency room or admission department. Registration of depressive symptoms on admission revealed that 85% had depressed mood and other depressive symptoms. According to the criteria established by Feighner et al. 51% suffered from definite depressive disease on admission. According to Zung's Depression Scale, 60% were depressed. On the basis of observations during hospitalization, 25% suffered from depressive disease according to the criteria established by Feighner et al. 19% of these patients suffered from endogenic depression according to the Newcastle I scale which corresponds to 5% of all the hospitalized patients with attempted suicide. Approximately 10% were treated with antidepressives. Only 8% were discharged with the diagnoses of endogenic or reactive psychoses (ICD-8). It is concluded that depressive symptoms occur in the majority of patients with attempted suicide but that slight non-endogenic depressive states are most commonly concerned and that many of these improve rapidly during hospitalization without medicinal treatment. Restraint should be observed in prescription of antidepressive medicine to patients with attempted suicide until the diagnosis of depressive disease is verified.

Personality, parental rearing behaviour and parental loss in attempted suicide: a comparative study.

Thirty psychiatric patients (aged 18-29) who had attempted suicide were compared with 2 matched control groups, one consisting of nonsuicidal psychiatric patients and the other of normal subjects, for personality patterns, parental rearing practices and personal loss before the age of 15. The instruments used were the Eysenck Personality Questionnaire (EPQ), the Lazare-Klerman-Armor Trait Scale (LKAS), the Narcissistic Personality Inventory (NPI) and the Own Memories of Child-Rearing Experiences (EMBU). Patients admitted for suicide attempts differed significantly from normals on several personality dimensions, whereas suicide attempters did not have personality characteristics that made them substantially different from nonsuicidal psychiatric controls. The suicide attempters had experienced significantly more negative and less positive parental rearing factors than normals, but no difference was found between suicidal and nonsuicidal patients for own memories of parental rearing patterns. Parental loss due to divorce had occurred significantly more often among suicide attempters than among both nonsuicidal psychiatric patients and normals.

[Sex differences in alcoholics at a psychiatric emergency clinic]. / Kønsforskelle blandt alkoholmisbrugere på en psykiatrisk skadestue.

All patients attending the psychiatric emergency clinic at Odense University Hospital in the period 2.9-6.10.1985 were interviewed by a psychiatric nurse and physician in order to determine disease pattern and social circumstances. The present investigation deals with sex distribution of alcoholics in the data collected. In the period, 141 patients with alcoholic problems were registered; of these 97 were men and 44 women. It was found that more female alcoholics than male were married/cohabiting. Unemployment was very high for both groups; almost 80 per cent being unemployed. A great number of the women had interpersonal conflicts, but apart from that the sex difference for amount of psychosocial strain was not significant. Drug abuse and affective reactions were significantly more frequent in women. More women than men were found to suffer from character neuroses, and more men than women were deviants, but this may be a reflection of a diagnostic tradition. It must be concluded that more similarities than differences were found between male and female alcoholics attending the psychiatric emergency department.

[Psychosocial strain among patients at a psychiatric emergency unit]. / Psykosocial belastning blandt patienter på psykiatrisk skadestue.

The frequency of psychosocial strain was systematically registered concerning 330 consecutive patients in the psychiatric emergency unit in Odense. Psychosocial strain was found in 211 patients (63.9%). In all, 551 stressful events were reported, which corresponds 2.5 per patient. Distribution of psychosocial strain by age, sex and civil status revealed no statistically significant correlation at the level of p less than 0.05, but there was a tendency towards greater strain among young persons, women and married/cohabiant patients. All those seeking education had psychosocial strain, while there were significantly fewer patients with psychosocial strain among early retirees and old age pensioners. The investigation showed that there were significantly fewer schizophrenic patients with psychosocial strain, and significantly more patients with strain were found among those with affective reactions and attempted suicides compared with the other patient categories. The most frequently occurring form of strain in all diagnosis groups was interpersonal conflict with a close person. In most cases the strain was not the result of an external catastrophe, and often the patient may himself have contributed in causing the psychosocial strain. This opens the possibility for socialpsychiatric intervention.

Cross-national study of perceived parental rearing behaviour in healthy subjects from Australia, Denmark, Italy, The Netherlands and Sweden: pattern and level comparisons.

Samples of healthy subjects from Australia, Denmark, Italy, The Netherlands and Sweden completed the EMBU, a Swedish questionnaire aimed at assessing the experience of parental rearing practices. For the purpose of comparison three factors - "emotional warmth", "rejection" and "overprotection" - obtained in a previous factor analytic study, have been used. The most pronounced differences occurred between the Dutch and the Swedish sample on the one hand, and the Italian and Australian sample on the other, with the Danish sample in between. Differences in perceived parental rearing should be considered when comparing personality characteristics and/or psychopathological conditions in subjects from different countries.