The Forensic High and Intensive Care Monitor: Measurement Properties of a Model Fidelity Scale for Contact-Based Care in Forensic Psychiatry.

Forensic High and Intensive Care (FHIC) has recently been developed as a new care model in Dutch forensic psychiatry. FHIC aims to provide contact-based care. To support Dutch forensic care institutions in the implementation of the model, a model fidelity scale was developed called the FHIC monitor. The aim of this study was to assess the inter-rater reliability, content validity, and construct validity of the FHIC monitor. A multi-methods design was used, combining qualitative and quantitative research. To collect data, audits and focus group meetings were organized to score care at individual wards with the monitor and get feedback from auditors and audit receiving teams about the quality of the monitor. In total, fifteen forensic mental healthcare institutions participated. The instrument showed acceptable inter-rater reliability and content validity, and a significant difference between expected high and low scoring institutions, supporting construct validity. The instrument can be used as a valid instrument to measure the level of implementation of the FHIC model on forensic psychiatric wards in the Netherlands.

Communities of Practice in Acute and Forensic Psychiatry: Lessons Learned and Perceived Effects.

In the Netherlands, two new approaches have been developed for acute and forensic psychiatry, called High and Intensive Care (HIC) and Forensic High and Intensive Care (FHIC). The models provide standards for temporary high-quality clinical care for patients in crisis and combine practices to reduce seclusion. To support the implementation of these approaches, Communities of Practice (CoPs) were created, including peer providers, mental health nurses, psychiatrists and managers. CoPs are increasingly used in healthcare. However, CoPs vary greatly in form and objective, and more insight is needed in the organisation and facilitation of CoPs. Therefore, the aim of this study is to gain insight into the lessons learned and perceived effects of the CoPs. A qualitative approach was used. Data were collected through focus groups (n = 3) with participants in the CoPs, feedback meetings with teams implementing HIC (n = 78) or FHIC (n = 23), and observations by the researchers. Data were analysed thematically. Lessons learned are: 1) create an ambassador role for CoP participants, 2) organize concrete activities, 3) take care of a multidisciplinary composition, and 4) foster shared responsibility and work on sustainability. Perceived effects of the CoPs were: 1) support of HIC and FHIC implementation, 2) creation of a national movement, and 3) further development of the HIC and FHIC approaches. The audits served as an important vehicle to activate the CoPs, and stimulated the implementation of HIC and FHIC. The findings may help others in creating a CoP when it comes to the implementation of best practices and improving healthcare.

Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations.

High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards.

Moral Dilemmas in Contact-Based Care: The Relevance of Moral Case Deliberation for Forensic Psychiatry.

Currently, forensic psychiatry shows a shift from a control-based to a contact-based approach. Working from contact may, however, entail new moral questions and dilemmas. How to secure safety when focusing on contact? Does contact imply being physically close to the patient, or should one refrain from intimate relations? In order to help care professionals to deal with these moral issues, clinical ethics support can be useful. A specific approach in clinical ethics support is moral case deliberation (MCD). An MCD is a structured dialogue between professionals on a moral issue they experience in practice, structured by a conversation method and guided by a facilitator. In this article, we describe the background and procedures of MCD. Furthermore, we present a case example in which care professionals reflect on the moral question of whether provision of care in forensic psychiatry may entail physical closeness. The MCD shows that an open conversation results in a better understanding of different perspectives and creates the basis for finding a joint way to proceed in the case. We conclude that MCD can enable professionals to reflect on moral issues and develop shared values in forensic psychiatry.

Pathways to experiencing mental problems and need for mental support in patients with pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) affects the physical and emotional wellbeing of patients. More information is needed regarding mental problems and preferences for support. Qualitative interviews were used to explore mental problems and preference for support of PAH patients. Additionally, a survey was used to assess the presence of mental problems (Problem List), distress (Distress Thermometer) and the need for mental support. In 24 semi-structured interviews, the following problem themes were identified: energy balance; loss of abilities; feeling misunderstood; and handling of worries and emotions. Need for support was based on an interplay between resilience to psychological distress, additional life problems, age, disease status, attitude towards professional help, and experienced support from significant others. The results from the survey highlight the need for professional support, as 50.8% of the 67 patients who completed the survey would consider support when offered, specifically when offered by a pulmonary hypertension (PH) professional. Younger age (odds ratio [OR] = 0.97, P = 0.04), depression (OR = 11.435, P = 0.001) and possibly anxiety (OR = 3.831, P = 0.069) were related to need for support. In conclusion, many patients with PAH are in need of mental support, which should be offered by a PH professional and tailored to phase of the disease and personal characteristics.