Telehealth experiences in Canadian veterans: associations, strengths and barriers to care during the COVID-19 pandemic.

INTRODUCTION: Identifying barriers to care in veteran populations is critical, as veterans face increased social isolation, relationship strains and financial insecurities. For Canadian veterans experiencing barriers to accessing healthcare, telehealth may be a promising alternative with comparable effectiveness to in-person services; however, the potential benefits and limitations of telehealth require further examination to determine its long-term utility, and to inform health policy and planning. The goal of the present research was to identify predictors and barriers to telehealth usage in Canadian veterans in the context of the COVID-19 pandemic. METHODS: Data were drawn from baseline data of a longitudinal survey examining the psychological functioning of Canadian veterans during the COVID-19 pandemic. Participants were 1144 Canadian veterans aged 18-93 years (Mage=56.24, SD=12.92; 77.4% men). We assessed reported telehealth use (ie, for mental healthcare, physical healthcare), healthcare access (ie, difficulty accessing care, avoidance of care) and mental health and stress since the beginning of the COVID-19 pandemic, sociodemographic variables and open-ended responses about telehealth experiences. RESULTS: Findings suggest that sociodemographic factors and previous telehealth use were significantly associated with telehealth use during the COVID-19 pandemic. Qualitative evidence highlighted both the benefits (eg, reducing barriers of access) and drawbacks (eg, not all services can be delivered) of telehealth services. CONCLUSIONS: This paper provided a deeper understanding of Canadian veterans' experiences with accessing telehealth care during the COVID-19 pandemic. While for some, the use of telehealth mitigated perceived barriers (eg, safety concerns of leaving home), others felt that not all health services could be appropriately carried out through telehealth. Altogether, findings support the use of telehealth services in increasing care accessibility for Canadian veterans. Continued use of quality telehealth services may be a valuable form of care that extends the reach of healthcare professionals.

Homelessness and housing crises among individuals accessing services within a Canadian emergency department.

ACCESSIBLE SUMMARY: Studies have indicated that individuals who are homeless access hospital emergency departments more frequently and may have different needs than individuals who are housed. Successful interventions have been developed and tested to reduce discharge to homelessness for psychiatric inpatients but have not been similarly tested for discharge from emergency departments. This study was developed to provide baseline data on this issue to inform future emergency department interventions. Findings from the current study suggest that discharge from emergency departments to homelessness happens frequently in London, Canada. Participants are unlikely to spontaneously disclose their housing/homelessness issue when first entering the emergency department, which may result in services that do not adequately meet their complex needs. Screening for housing issues is necessary within emergency departments and psychiatric crisis teams as housing issues may be a reason for accessing care or contribute to the presenting condition. Nurses are in an ideal position to evaluate housing needs among emergency department patients. Services outside of the emergency department are also needed to address housing issues, particularly outside of regular office hours. ABSTRACT: Individuals who have mental health issues and are homeless or in housing crisis have been found to access emergency departments more frequently than individuals with stable housing. While emergency departments primarily focus on medical issues, homeless individuals may require psychosocial support as well. This study examined issues around housing crises and emergency department use for individuals with mental illness in Canada. Collecting baseline data about these issues is important to inform subsequent interventions. Administrative data from a hospital emergency department and psychiatric crisis service were collected, and five individuals accessing the emergency department for psychiatric reasons were interviewed. Results indicated that individuals with an identified housing crisis accessed the emergency department 930 times in 6 months. None of the interview participants identified housing as the primary reason for accessing the emergency department, but all noted that housing was a contributing stressor. Future research is needed to examine ways in which discharge to homelessness from emergency departments can be avoided and identify alternative services to address housing concerns, particularly for individuals with mental illness. Crisis service and emergency department staff, especially nurses, can play an important role in screening for housing issues and connecting individuals to outside services.

Integrating an evidence-based intervention into clinical practice: 'transitional relationship model'.

The transitional relationship model (TRM) facilitates the discharge process by providing peer support and hospital staff involvement until a therapeutic relationship has been established with a community care provider. A quasi-experimental, action-oriented research design was employed in which psychiatric wards at six hospital sites implemented the model in three waves. Helpful strategies were identified by each wave of wards for consideration by subsequent wards. Using an ethnographic approach, qualitative data were examined to uncover experiences and perceptions of TRM implementation and to help identify key issues that were supporting or hampering implementation. Specific strategies that facilitate the implementation of TRM include: (1) the use of educational modules for on-ward hospital staff training and peer training; (2) presence of on-site champions; and (3) supportive documentation systems. Issues identified as barriers to implementation included: (1) feeling drowned, swamped and overwhelmed; (2) death by process; (3) team dynamics; and (4) changes in champions. Staged large-scale implementation of the TRM allowed for iterative improvements to the model leading to positive outcomes. This study highlights the need to address work environment issues, particularly interprofessional teams.

Mothers with mental illness experiencing homelessness: a critical analysis.

The experiences of homeless mothers with mental illness were examined from the critical perspective of feminist intersectionality. The purpose of this study was to unveil experiences of oppression and resistance in the lives of homeless mothers with mental illness, while learning from them what is conducive to their health. A qualitative secondary analysis was done using focus group transcripts from a study examining issues related to diversity and homelessness for psychiatric survivors and a study on mental health and housing. A purposive sample of 7 focus groups comprised of 67 participants was used for this study. Findings revealed three overarching themes: (1) discrimination based on intersecting social identities; (2) being stuck: the cycle of oppression; and (3) we're not giving up: resistance through perseverance. The contextual influences of mothering while homeless with a mental illness were emphasized in the results. The findings illuminate the need for increased on ongoing advocacy at individual and structural levels.

Developing and testing an intervention to prevent homelessness among individuals discharged from psychiatric wards to shelters and 'No Fixed Address'.

Shelter data in a recent study revealed discharges from psychiatric facilities to shelters or the street occurred at least 194 times in 2002 in London, Ontario, Canada. This problem must be addressed to reduce the disastrous effects of such discharge, including re-hospitalization and prolonged homelessness. An intervention was developed and tested to prevent homelessness associated with discharge directly to no fixed address. A total of 14 participants at-risk of being discharged without housing were enrolled, with half randomized into the intervention group. The intervention group was provided with immediate assistance in accessing housing and assistance in paying their first and last month's rent. The control group received usual care. Data was collected from participants prior to discharge, at 31 and 6-months post-discharge. All the individuals in the intervention group maintained housing after 3 and 6 months. All but one individual in the control group remained homeless after 3 and 6 months. The exception joined the sex trade to avoid homelessness. The results of this pilot were so dramatic that randomizing to the control group was discontinued. Discussions are underway to routinely implement the intervention. Systemic improvements can prevent homelessness for individuals being discharged from psychiatric wards.

Perceptions of health and health service utilization among homeless and housed psychiatric consumer/survivors.

Homelessness has a direct impact on health. Homeless individuals report several barriers to accessing health care. Although research exists regarding the utilization of health services for homeless and housed psychiatric consumer/survivors, few studies have compared the perceived health and service utilization of these two groups. The objective of this study was to determine whether or not differences exist between the utilization of health services and the perceptions of health of homeless and housed psychiatric consumer/survivors in London, Ontario, Canada. It was hypothesized that differences would exist between homeless and housed psychiatric consumer/survivors on all health-related variables examined. A secondary analysis of quantitative data was conducted in a Community-University Research Alliance on Mental Health and Housing project funded by the Social Sciences and Humanities Research Council of Canada. Key findings include significant differences in the characteristics of each population, the use of health services and their perceptions of health. Implications for practice and policy are discussed.

Peer support relationships: an unexplored interpersonal process in mental health.

Consumer-survivors (C/Ss) identify peer support as a resource that facilitates their recovery. However, little is known about the factors that influence or how the peer support relationship (PSR) develops/deteriorates. The purpose of the study was to explore and describe the PSR within the subculture of mental health. Using an ethnonursing method, the study focused on informants from two C/S organizations who received peer support (n = 14). Findings revealed that the PSRs may develop or deteriorate through three, overlapping phases. Contextual factors that influenced the development/deterioration of the PSR are discussed. Understanding the processes and factors that contribute to the development/deterioration of PSRs will enable clinicians and C/Ss to assess and promote the development of healthy, supportive PSRs in mental health.

From psychiatric ward to the streets and shelters.

The issue of discharge from hospital ward to the streets is seldom explored in the literature, but all too commonly experienced by individuals experiencing psychiatric disorders. The Community University Research Alliance on Housing and Mental Health sought to determine how frequently people were discharged from psychiatric wards to shelters or the street in London, Ontario, Canada. A number of data sources were accessed to determine instances of discharges to shelters or the street. Data were analysed to determine the number of moves occurring between hospital and shelter or no fixed address. All datasets revealed the problem of discharge to shelters or the street occurred regularly. All data sources used have the difficulty of likely underestimating the extent of the problem. This type of discharge occurred at least 194 times in 2002 in London, Ontario, Canada. Policies that contribute to this problem include income-support policies, the reduction in psychiatric hospital beds and the lack of community supports. Without recognition, this problem is at risk of remaining invisible with no further improvements to the situation.

Nurse-client processes in mental health: recipients' perspectives.

An ethnonursing method was selected to explore and describe nursing support relationships, from the perspectives of recipients, within the mental health subculture. Data sources consisted of three semi-structured client interviews (n = 14) and field notes. When nurses were described as nice and friendly, and validated the client as a person by listening, three overlapping phases of development emerged from the data. These included: a glimmer of help, exploring and problem solving, and saying goodbye. When clients had negative experiences with nurses, they felt a lack of trust towards nurses and felt that their feelings were left unexplored. As a result, the relationships deteriorated. Deterioration began immediately in the first phase called withholding, and continued through the phases of avoiding and ignoring, and struggling with and making sense of. These findings raise healthcare providers' awareness about developing and deteriorating nurse-client relationships, and support the value of the therapeutic relationship as an instrument to restore and promote clients' health.

Therapeutic relationships: from psychiatric hospital to community.

The objective of this study was to determine the cost and effectiveness of a transitional discharge model (TDM) of care with clients who have a chronic mental illness. The model was tested in a randomized clinical trial using a cluster design. This model consisted of: (1) Peer support for 1 year and (2) Ongoing support from hospital staff until a therapeutic relationship was established with the community care provider. Participants (n = 390) were interviewed at discharge, 1 month post-discharge, 6 months post-discharge and 1 year post-discharge. Data collected included demographics, quality of life, health care utilization, levels of functioning and the degree of intervention received. The intervention group post-discharge costs and quality of life were not significantly improved compared with the control group. Although not predicted a priori, intervention subjects were discharged an average of 116 days earlier per person. Based on the hospital per diem rate this would be equivalent to 12M dollars CDN hospital costs. Both under-implementation among implementation wards and contamination in control wards were found. This study demonstrates some of the multiple challenges in health system research.

Role changes experienced by clinical staff in relation to clients' recovery from psychosis.

This study investigates the subjective experiences of staff from many interdisciplinary teams working with clients in the recovery process from psychosis. The clinical staff interviewed in this study included: staff nurses, clinical nurse specialists, occupational therapists, psychologists, social workers, rehabilitation workers, recreation therapists, music therapists, psychiatrists, and lodging home operators. The purpose of this study was to examine the clinical staff's changing roles and relationships with clients recovering from psychosis. The investigation used a naturalistic qualitative design with an ethnographic method of data analysis. The participants were clinical staff working with clients about to commence treatment with clozapine or risperidone. The settings used were a tertiary-care psychiatric hospital and a general hospital. The clinical staff members who participated in the study were interviewed every 3 months. In the initial interview, members of the clinical staff were asked about their knowledge regarding the new medication and their role in the decision to try the new medication. In all the interviews, clinical staff members were asked about how the recovery process was progressing with the client. Data regarding clinical staff fears related to the client's situation, changes in their relationships with the client and the client's family, and what they perceived to be current rehabilitation implications, were collected. Some of the clinical staff roles that evolved during the recovery process were: health teacher; advocate; counsellor; and support person.

Celebrating our past. The history of Hamilton Psychiatric Hospital.

1. There is a risk of losing important parts of our psychiatric nursing history as a result of the rapid rate of mental health reform and the closing or changing of governance of major psychiatric facilities. 2. Hamilton Psychiatric Hospital provided leadership in psychiatric nursing in Canada for more than a century and is now changing governance from being a provincial psychiatric hospital to part of a community general hospital. 3. The hospital's tradition includes nonrestrictive care policies that have been in place for more than a century, a humanistic approach to care, being the first facility in Canada to require theory-based nursing care from all nursing staff, innovative practice models, and achieving authorship or co-authorship from more than 17% of the RN staff.

Factors associated with readmission to a psychiatric facility.

This study examined patient-related factors that were associated with readmission to a tertiary care psychiatric hospital in Canada. The charts of a random sample of 200 patients were reviewed from an index discharge date in 1991 through subsequent rehospitalizations over the next three years. Eighty-eight patients (44 percent) were readmitted at least once. The only variable that significantly differentiated patients who were readmitted from those who were not was a history of admission. System variables or factors that are not patient related, such as staff attitudes and perceptions, may contribute to readmission and thus may warrant further exploration.

Clients' reflections on relationships with nurses: comparisons from Canada and Scotland.

It has been suggested that the crucial elements in nursing situations are the nurse, the client, and what goes on between them. This paper examines what goes on between clients and nurses during interpersonal relationships, from the perspective of the clients. Data are presented from studies conducted in Canada and Scotland. It is shown that what clients want, or do not want, during relationships with their nurses, is similar on both sides of the Atlantic. The findings reported in this paper are relevant to transcultural nursing, ethical care, the growth in consumerism, and client advocacy. The findings suggest also that there is a need for nursing research to focus on clinical outcomes in order to establish whether clients' perceptions of helping relationships have any relevance to favourable health outcomes, and the evidence base for clinical nursing.

Strike contingency planning.

On Monday, February 26, 1996, the Ontario Public Service Employees Union (OPSEU) went on strike. The month-long strike included the 10 provincial psychiatric hospitals in Ontario. Within the psychiatric hospitals, the included direct care providers--RNs, RPNs, psychologists, social workers, occupational therapists--as well as support workers (food service, maintenance, housekeeping, and office employees). In anticipation, the mental health program at the London Health Science Centre (LHSC) developed a contingency plan that went into action when the strike was announced. This paper outlines the plan, describes what happened and makes recommendations for nurses who may be faced with similar situations.

Factors influencing movement of chronic psychiatric patients from the orientation to the working phase of the nurse-client relationship on an inpatient unit.

PROBLEM: To identify factors influencing movement of nurse-patient dyads from Peplau's orientation phase to the working phase of the nurse-client relationship in a tertiary care psychiatric setting. METHODS: Ten nurse-client dyads were interviewed after the initial nurse-client assignment until a consensus was reached between client, nurse, and investigator/CNS that the relationship was in the working phase. FINDINGS: Factors causing the relationship to progress, from the clients' perspective, were the perceived attitude of the nurse, the nature of the planned therapeutic sessions, and what happened between therapeutic sessions. Factors hindering the development of the relationship included a nurse's or client's unavailability, a sense of distance/inequity, differences in realities/values, and mutual withdrawal. The relationship was perceived as supportive and "powerful" when it progressed to the working phase, but as very negative and like "limbo" if instead it moved to a phase of mutual withdrawal. CONCLUSIONS: Nurses can help clients move from the orientation phase to the working phase by remaining available, consistent, and acting in a way that promotes trust. When the relationship does not progress to the working phase within 6 months, a therapeutic transfer should be considered.

From hospital to community: bridging therapeutic relationships.

The 'Bridge to Discharge' project evolved from a participatory research project. The team included public health nurses, in-patient schizophrenia program nurses and mental health consumers. The project focused on therapeutic relationships and used Peplau's theory of Interpersonal Relations. A broad perspective of therapeutic relationships was used that explicitly included both peer and professional support. The theoretical approach is described and illustrated with a case study.