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Routine Outcome Monitoring in de forensische psychiatrie: Implementatie in de medium security unit van Zelzate
... Insight into these preconditions can help to further introduce systematic aggression registration in other (forensic) psychiatric units, resulting in tailored-made aggression and future risk management plans. The framework of Boswell and colleagues (2015) includes three crucial processes that help to clearly discuss preconditions of a good implementation of Routine Outcome Monitoring (ROM) instruments for measuring treatment progress (De Varé et al., 2017;Vess, 2001), i.e., (1) creating the most appropriate context for introduction, (2) choosing a relevant instrument and (3) perpetuating the use in clinical practice. The first process refers to recognizing and overcoming institutional and practical (e.g. ...
... relevance, monitoring function, preconditions for implementation), the same thematic structure was used for both types of data, and the focus group data were seen as a further elaboration of the interview data. When discussing this thematic tree structure, a similarity with the preconditions for introducing routine outcome monitoring in clinical practice came to the fore (Boswell et al., 2015;De Varé et al., 2017). Therefore, the decision was taken to reorganize the thematic structure of the interviews and focus group data in these three preconditions: (1) creating the most appropriate context for introduction, (2) choosing a relevant instrument and (3) perpetuating the use in clinical practice. ...
... The first referred to installing a registration culture supported by the hospital management. In order to achieve this, it is important to have stakeholders who "carry out" this registration culture and boost it from time to time by training courses for both new and experienced staff members (De Varé et al., 2017). These stakeholders should be attentive for resistance or a diminishing drive to register these incidents. ...
Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.
Purpose:
Aim of this study was to develop a brief version of the Forensic inpatient Quality of Life questionnaire (FQL).
Methods:
Data from a longitudinal study of quality of life (QoL) among long-term forensic psychiatric care (LFPC) patients (N = 130) were used. Per domain, the FQL item that correlated most highly with the mean domain score and Overall QoL was selected. Internal consistency was investigated by calculating Cronbach's alpha. Construct validity was examined by investigating the relationship with the WHOQOL-Bref and EssenCES.
Results:
The original division into 15 QoL domains was retained, while the number of items per domain was reduced to one or two. The amount of subjective items was shortened from 114 items to 19 items. Reliability analysis demonstrated good internal consistency (Cronbach's α = .79). Content validity was assured because the FQL-SV is based on the items of the original FQL that was derived from LFPC patient's and staff's opinions. Construct validity was demonstrated.
Conclusions:
This study has shown that the FQL-SV is a psychometrically valid abbreviation of the FQL and can therefore be used to monitor or assess QoL in forensic psychiatric care. However, when certain domains should be targeted in treatment, the FQL (full version) can assist both the patient and the clinician to get a more complete view of the individualized targets they should be aiming at in order to improve QoL.
Abbreviated version of the Forensic inpatient Quality of Life Questionnaire (Dutch)
Abstract This article reviews the benefits, obstacles, and challenges that can hinder (and have hindered) implementation of routine outcome monitoring in clinical practice. Recommendations for future routine outcome assessment efforts are also provided. Spanning three generations, as well as multiple developed tools and approaches, the four authors of this article have spent much of their careers working to address these issues and attempt to consolidate this learning and experience briefly here. Potential "elephants in the room" are brought into the discussion wherever relevant, rather than leaving them to obstruct silently the field's efforts. Some of these topics have been largely ignored, yet must be addressed if we are to fulfill our promise of integrating science and practice. This article is an attempt to identify these important issues and start an honest and open dialogue.
Outcome research has documented worsening among a minority of the patient population (5% to 10%). In this study, we conducted a meta-analytic and mega-analytic review of a psychotherapy quality assurance system intended to enhance outcomes in patients at risk of treatment failure.
Original data from six major studies conducted at a large university counseling center and a hospital outpatient setting (N = 6,151, mean age = 23.3 years, female = 63.2%, Caucasian = 85%) were reanalyzed to examine the effects of progress feedback on patient outcome. In this quality assurance system, the Outcome Questionnaire-45 was routinely administered to patients to monitor their therapeutic progress and was utilized as part of an early alert system to identify patients at risk of treatment failure. Patient progress feedback based on this alert system was provided to clinicians so that they could intervene before treatment failure occurred. Meta-analytic and mega-analytic approaches were applied in intent-to-treat and efficacy analyses of the effects of feedback interventions.
Three forms of feedback interventions-integral elements of this quality assurance system-were effective in enhancing treatment outcome, especially for signal alarm patients. Two of the three feedback interventions were also effective in preventing treatment failure (clinical support tools and the provision of patient progress feedback to therapists).
The current state of evidence appears to support the efficacy and effectiveness of feedback interventions in enhancing treatment outcome.
This article describes the implementation of a computer assisted treatment planning and outcome evaluation process in a forensic psychiatric state hospital with a census of approximately 1000 patients. This process utilizes standardized assessment measures of patient functioning and facilitates the assignment of treatment activities that are explicitly related to assessed deficits. Beyond individual patient treatment planning, data generated in the course of computer assisted treatment planning are used in conjunction with other sources of datafor outcome evaluation and program development.
Besides assessment of forensic patients’ risk of future violence and criminogenic needs, knowledge on their responsivity to treatment is equally important. However, instruments currently used for risk assessment are not sensitive enough for treatment evaluation. Therefore, the Instrument for Forensic Treatment Evaluation (IFTE) was developed. The IFTE is a treatment evaluation tool, which uses the dynamic risk items of the Dutch risk assessment tool, the HKT-R (Historical, Clinical, Future–Revised). The IFTE has an extended answering scale, which makes it more sensitive for measuring change and enables clinicians to monitor patients’ responsivity to treatment closely. This study examines the concurrent and predictive validity of the IFTE. We found moderate to strong correlations between IFTE items and HKT-30 items (the HKT-30 is the predecessor of the HKT-R), with work and therapy attendance, and positive drug tests. In addition, we found moderate to modest correlations between some IFTE items and work and therapy attendance in a 6-month follow-up period and modest to high discriminative power for some IFTE items for violence and drug use 6 months after the measurement. Given its good reliability and validity properties, and comprehensive but short-term nature, implementation of the IFTE in forensic practice likely improves individual treatment of forensic psychiatric patients and has high potential for risk management purposes.
To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.
The number of aggressive incidents committed by patients in (secure) mental health care is high. The present study examined the relation between institutional climate (support, growth, atmosphere, and repression) and aggressive incidents using data of 72 patients in a secure (forensic) mental health clinic and a clinic for prolonged intensive care. Longitudinal analyses showed that support from nurses was negatively associated with aggressive incidents. The relation between growth and aggressive incidents was mediated by support. Mental health nurses could have an important contribution to decreasing aggression incidents in secure mental health care facilities by offering support and possibilities for growth to the patients.
In this study, the Instrument for Forensic Treatment Evaluation (IFTE) is introduced. The IFTE includes 14 dynamic items of the risk assessment scheme HKT-R and eight items specifically related to the treatment of forensic psychiatric patients. The items are divided over three factors: protective behavior, problematic behavior and resocialization skills. Inter-rater reliability and test-retest reliability ranged from moderate to almost perfect in a Dutch population of 232 forensic patients. Factor analysis largely confirmed the factor
structure. The IFTE is evaluated to be a reliable routine outcome monitoring instrument for supporting and indicating inpatient forensic psychiatric treatment evaluations and processes.
Although aggression is part of daily life in psychiatric units for adolescents, empirical data on its prevalence are sparse. Only few studies have described prevalence of aggressive incidents in adolescent psychiatric wards, and data in forensic psychiatric care are even more limited. Available studies reported high prevalence rates of aggression, ranging from 0.4 to 2.4 incidents of aggression per day across (forensic) child and adolescent psychiatric units. Between 27 and 78 % of all admitted
youth committed an aggressive act. In this study, we collected
systematically registered data of all aggressive incidents from the first 2 years (2010–2012) on a newly established forensic adolescent psychiatric unit, which used a formal aggression management program embedded in the social competence model, which is based on early intervention in the ‘chain of behavior’ to prevent any further escalation. The inclusion of also minor aggressive incidents is unique in the literature and the clinical relevance is highlighted. A mean of one incident a day took place, with each adolescent involved in at least one incident.
Notably, 1.7 aggressive incidents per month made seclusion of restraint use necessary. Based on the social competence theory, the aggression management model suggests intervening early in the cascade of aggression, in order to prevent further escalation and reduce the need for intrusive interventions. Evidence supported that aggression is a contextual event, as external factors clearly influence the incidence of aggression. Aggression management should be built on both relational and structural security.
Concept mapping is a structured method for translating complex qualitative data into a pictorial form that displays the interrelationships among ideas. Over the past ten years, this methodology has been applied to numerous program planning and program evaluation issues in a variety of disciplines. The ability to adapt concept mapping methodology to meet specialized needs and to accommodate external constraints has been demonstrated during this period. This paper describes the use of concept mapping in the field of community mental health. Investigators have used concept mapping for purposes ranging from mental health needs assessment to studying program models and theory. Adaptations to the methodology have been applied to the ways in which the qualitative data are generated, structured, represented, and interpreted. Examples from the mental health literature are presented to illustrate these purposes and adaptations. The contributions and value of concept mapping to the mental health field are discussed.
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