Brooks Helen, Harris Kamelia, Bee Penny, Lovell Karina, Rogers Anne, Drake Richard
Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL UK.
Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL UK.
Int J Ment Health Syst. 2017 Jun 28;11:42. doi: 10.1186/s13033-017-0149-z. eCollection 2017.
As a response to evidence that mental health service users and carers expect greater involvement in decisions about antipsychotic medication choice and prescribing, shared decision-making (SDM) has increasingly come to be viewed as an essential element of person-centred care and practice. However, this aspiration has yet to be realised in practice, as service users and carers continue to feel alienated from healthcare services. Existing understanding of the factors affecting the use of tools to support SDM is limited to inter-individual influences and wider factors affecting potential implementation are underexplored.
To explore the potential use of a tool designed to enhance collaborative antipsychotic prescribing from the perspectives of secondary care mental health service users, carers and professionals.
We conducted a qualitative study (semi-structured interviews and focus groups) using a convenience sample of 33 participants (10 mental health service users, 10 carers and 13 professionals) involved in antipsychotic prescribing in one Trust in the North of England. Participants were asked about the potential implementation of a tool to support SDM within secondary mental health services. Framework analysis incorporating the use of constant comparative method was used to analyse the data.
The study identified a divergence in the views of service users and professionals, including a previously undocumented tendency for stakeholder groups to blame each other for potential implementation failure. This dissonance was shaped by meso and macro level influences relating to paternalism, legislative frameworks, accountability and lack of resources. Participants did not identify any macro level (policy or structural) facilitators to the use of the tool highlighting the negative impact of mental health contexts. Our study indicated that inter-individual factors are likely to be most important to implementation, given their potential to transcend meso and macro level barriers.
Consideration of the meso and macro level influences identified areas for potential intervention, including challenging professionals' and service users' perceptions of each other, rebalancing the notion of accountability within services and introducing new means for service user feedback on the quality of SDM. Multi-level strategies for facilitating the implementation of tools to support SDM are also presented.
有证据表明，精神卫生服务使用者及护理人员期望更多地参与到抗精神病药物选择及处方开具的决策中，作为对此的回应，共同决策（SDM）日益被视为以患者为中心的护理与实践的关键要素。然而，这一愿望在实践中尚未实现，因为服务使用者和护理人员仍感觉与医疗服务脱节。目前对于影响支持共同决策工具使用的因素的理解仅限于个体间影响，而对影响潜在实施的更广泛因素的探索不足。
从二级护理精神卫生服务使用者、护理人员及专业人员的角度，探讨一种旨在加强抗精神病药物联合处方开具的工具的潜在用途。
我们进行了一项定性研究（半结构化访谈和焦点小组），采用便利抽样法，选取了33名参与者（10名精神卫生服务使用者、10名护理人员和13名专业人员），他们来自英格兰北部一个信托机构中参与抗精神病药物处方开具工作的人员。参与者被问及在二级精神卫生服务中支持共同决策的工具的潜在实施情况。采用结合持续比较法的框架分析法对数据进行分析。
该研究发现服务使用者和专业人员的观点存在分歧，包括利益相关者群体之间此前未被记录的一种倾向，即相互指责潜在的实施失败。这种不一致是由与家长作风、立法框架、问责制和资源匮乏相关的中观和宏观层面影响所塑造的。参与者未识别出该工具使用的任何宏观层面（政策或结构）促进因素，凸显了精神卫生环境的负面影响。我们的研究表明，个体间因素可能对实施最为重要，因为它们有可能超越中观和宏观层面的障碍。
对中观和宏观层面影响的考量确定了潜在干预领域，包括挑战专业人员和服务使用者对彼此的看法、重新平衡服务中的问责概念，以及引入服务使用者对共同决策质量进行反馈的新方式。还提出了促进支持共同决策工具实施的多层次策略。
