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The head nurses’ perceptions of the impact of deinstitutionalization on the chronically mentally ill Sinnen, K. Leila 1993

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THE HEAD NURSES' PERCEPTIONS OF THE IMPACT OFDEINSTITUTIONALIZATION ON THE CHRONICALLYMENTALLY ILLbyK. LEILA SINNEN, R.P.N., R.N.B.S.N. The University of British Columbia, 1987A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGINTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conformingequired^rdTHE UNIVERSITY OF BRITISH COLUMBIAApril 1993© K. Leila Sinnen, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Sc,LA00Depaftfoe nt ofThe University of British ColumbiaVancouver, CanadaDate DE-6 (2/88)1 1ABSTRACTThis study describes head nurses' perceptions of the impact ofdeinstitutionalization on persons with chronic mental illness. Aphenomenological approach is the methodology used in this study. Datawere collected by use of an in-depth semi-structured interview. Theparticipants in the study were seven head nurses from a large psychiatricinstitution in Western Canada.Themes derived from the data were abstracted into three contentcategories. The content categories are contributing factors, impact on theindividual and facilitating factors. Major themes under each of the contentcategories are described. The findings reveal that head nurses perceive thatdeinstitutionalization has negative and positive effects on the chronicmentally ill. The negative effects are stigma, homelessness and therevolving door syndrome. Positive effects of deinstitutionalization can be abetter quality of life with adequate communication, patient preparation,education and resources/facilities in the community. The findings also showthat head nurses perceive that some persons with chronic mental illnessmay require care in a psychiatric institution for most of their lives. Theimplications that deinstitutionalization has for nursing practice, education,administration and research are presented.111TABLE OF CONTENTSPageABSTRACT ^  iiTABLE OF CONTENTS ^  iiiLIST OF FIGURES  vACKNOWLEDGEMENTS ^  viCHAPTER ONE: Introduction  1Background and Conceptualization of the Problem ^ 1Problem Statement ^  4Purpose of the Study  5Research Question  5Operational Definition of Terms ^  5Asssumptions ^  6Limitations  6Significance of the Study  7Scientific Significance ^  7Practical Significance  7Summary ^  8CHAPTER TWO: Literature Review ^  9Historical Perspective of Deinstitutionalization ^ 9Impact of Deinstitutionalization  12Current Status of the Canadian Mental Health System ^ 16Summary ^  20CHAPTER THREE: Methods ^  21Research Design  21Sample Selection and Selection Criteria ^  22Data Collection Procedures  23Data Analysis ^  25Ethical Considerations ^  27Summary ^  28CHAPTER FOUR: Presentation of Findings ^  29Description of the Participants ^  29Conceptualization of the Data  30Contributing Factors ^  31Hospital Mandate to Downsize  33Mental Health Act  35Consumer Advocacy  38Impact on the Individual ^  41Stigma ^  41ivTABLE OF CONTENTS(Continued)PageHomelessness ^  42Revolving Door Syndrome ^  43Quality of Life  44Facilitating Factors  45Communication ^  46Patient Preparation  49Education  50Resources and Facilities ^  51Summary ^  52CHAPTER FIVE: Discussion of Findings  55Contributing Factors ^  56Hospital mandate to downsize ^  56Mental Health Act  57Consumer Advocacy  58Impact on the Individual ^  59Stigma ^  59Homelessness  59Revolving Door Syndrome ^  60Quality of Life ^  60Facilitating Factors  61Communication  61Patient Preparation  62Education ^  62Resources and Facilities ^  63Summary  63CHAPTER SIX: Summary, Conclusions and Implications ^ 64Summary ^  64Conclusions  67Implications for Nursing Practice ^  68Implications for Nursing Education  69Implications for Nursing Administration  70Implications for Nursing Research  71REFERENCES ^  73APPENDIX A: Letter to the Agency ^  79APPENDIX B: Consent Form  81APPENDIX C: Trigger Questions ^  83VLIST OF FIGURESPageFig 1. Conceptualization of Deinstitutionalization of the ChronicallyMentally Ill ^  32viACKNOWLEDGEMENTSThis thesis is dedicated to my parents who instilled the value ofeducation in me as I was growing up. I know they would have been veryproud of my achievement today.More important, I sincerely thank my husband Sam, for supportingme unconditionally for the past five years as I pursued my goal. I knowthere were difficult times but he stood beside me and gently pushed meforward when it was necessary. A big thank you to my children Myron andDiandra who loved me even when I had little time to spend with them.A special thank you to my wonderful father-in-law who stayed up lateat nights to type for me so that I could meet deadlines. Dad you havegraduated too!Thank you to my thesis chairperson, Dr Joan Anderson for themotivation and encouragement, and also to Dr. Sonia Acorn for the supportand smiles. Thanks to Donelda Ellis for her critical third reading.Particular thanks go out to the seven head nurses, my researchparticipants, for willingly sharing their knowledge and experience.Lastly, to Alice Choi, thank you for being my friend.1CHAPTER ONEIntroductionDeinstitutionalization of the chronically mentally ill from provincialand state hospitals has been a trend in mental health care for the pastthirty years. The effect of deinstitutionalization on the chronically ill andtheir ability to survive in the community has been documented to someextent. What is lacking is information (or understanding) about theperceptions of nurses on the impact of deinstitutionalization on personswith chronic mental illness.Background and Conceptualization of the ProblemDeinstitutionalization is "the trend to discharge large numbers ofchronically mentally ill patients to the community from psychiatricinstitutions and the reduction in hospitalization of the chronically mentallyill" (Bachrach, 1984, p. 974). Deinstitutionalization of chronically mentallyill patients from psychiatric hospitals has been a major movement inpsychiatry for the past thirty years. A policy of deinstitutionalization wasimplemented in both Canada and the United States in the 1960s. "In theU.S.A, community treatment programs have multiplied since the 1960swhile in Canada the organization of a network of programs did not officiallybegin until the early seventies" (Hodgins, 1987, p. 8). Brook (1990) states"presently in the Netherlands mental health care is undergoing anextensive revision. Current mental health care policy emphasizes a major2shift from intramural to extramural care." In 1978 major psychiatric reformdrastically changed the Italian psychiatric system. Mental hospitals stoppedadmitting patients and psychiatric units in general hospitals beganaccepting clients (Berti, Glick & Tansella, 1990).According to Talbot (1988) there were 560,000 patients in statehospitals in the U.S.A in 1955 as compared to 115,000 in 1987. In Englandthe number of psychiatric patients in hospital in 1954 was 150,000 whilst in1985 there was a dramatic reduction to 73,000 (Corke, Cushion & Haddock,1989).According to statistics Canada (personal communication March 28,1991) statistics are not available on patients institutionalized in psychiatrichospitals in Canada. However, in 1987 - 1988 the number of discharges ofpsychiatric patients from psychiatric and acute care hospitals was 194,306in Canada of which 22,518 were in British Columbia.The provincial psychiatric hospital in British Columbia, with bedsreduced from 4,800 in the 1960s to 900 patients today, has been in a"downsizing phase" for the past four years and is scheduled to complete thisphase within ten years. The completed phase will result in a 500 bedhospital for psychiatric patients (The Vancouver Sun 1990; Province 1990;Ministry of Health, 1989). However, the deinstitutionalization experiencehas not been successful for many chronically mentally ill. Adjusting to lifeafter hospitalization is a major problem among psychiatric patients (Crosbie,31987). Most of these patients, who have poor coping skills and/or inadequatesupports in the community, fail to function and are rehospitalized.Many people with a chronic mental illness become caught up in thedepartment (personal communication July 13, 1992) this psychiatric hospitaladmitted 512 patients in the past six months. Of the 512 patients,approximately 98% had had previous admissions to the hospital.Head nurses who work with people with chronic mentalillness in psychiatric hospital settings are aware that their patients requiredifferent levels of community support upon discharge to prevent the highrate of recidivism that occurs. In addition, head nurses are cognizant oftheir patients' needs as they are responsible for assessing, planning,implementing and evaluating nursing care for their patients on a twenty-four basis. In their role as leaders, head nurses have close contact with alarge number of nursing staff, multi-disciplinary team members, communityhealth care providers, families and administrators who actively participatein the deinstitutionalization process.By virtue of their psychiatric nurse training, clinical experience anddepth of knowledge gained from working with this population, head nurseshave become "experts" and are well equipped to influence the process ofdeinstitutionalization effectively. As well, head nurses "contribute to bothtreatment of illness and the maintenance of health. They recognize the high4cost of health care and as professionals endeavour to control expenses"(Parker, 1986, p. 22).Head nurses at a large psychiatric hospital in Western Canada, areclinically and administratively involved, at the ward level, in theoperationalization of deinstitutionalization. Their years of clinicalexperience and knowledge of the theory of nursing the chronically mentallyill can be useful in the decision-making process affectingdeinstitutionalization.However, it is the experience of this investigator that the expertise ofhead nurses is not fully utilized and at times their views are disregarded.Often decisions affecting patient care, are made with very little input fromthe head nurses. Their involvement in decision-making above the ward levelregarding the placement of the chronic mentally ill patients in thecommunity would enhance the policy decisions regarding this population.Problem StatementHead nurses hold a strategic position within the nursing hierarchy toinfluence the health care of patients. More specifically they can contributesignificantly to the decisions affecting the implementation ofdeinstitutionalization. Yet their knowledge and expertise are not activelyutilized. Head nurses need to articulate their perception of the impact ofdeinstitutionalization on the chronically mentally ill.5Purpose of the StudyThe purpose of the study was to determine head nurses' perceptionsof the impact of deinstitutionalization on persons with a chronic mentalillness. The information gained will assist health care administrators andpolicy planners to understand the needs of this patient population. Inaddition this information will contribute to the improvement of patient careand enhance the process of implementing deinstitutionalization.Research QuestionWhat are head nurses' perceptions of the impact ofdeinstitutionalization on the chronically mentally ill?Operational Definition of TermsChronic mental illness - mental illness that requires frequent short term orlong term psychiatric treatment.Community living - private homes, government subsidized or privateboarding homes, hotels, hostels or places where patients reside upondischarge from the institution with the exception of prison andthe street.Deinstitutionalization - "the trend to discharge large numbers of chronicallymentally ill patients to the community from psychiatric institutionsand the reduction in hospitalization of the chronically mentally ill"(Bachrach, 1984, p. 976).6Head nurse - registered psychiatric nurse or registered nurse selected andappointed in charge of a ward. The head nurse is responsible for theoverall clinical and administrative management of his/her ward.Impact - a strong or powerful effect or impression.Perception - insight, awareness and understanding.Asssumptions1. The problems associated with deinstitutionalization are concerns forsociety.2. Some chronically mentally ill patients prefer to live in thecommunity while some prefer the institution.3. Some chronically mentally ill patients do not have the skills forcommunity living.4. Head nurses possess good clinical and theoretical knowledge ofchronic mental illness and the impact of deinstitutionalization on thechronically mentally ill.5. Head nurses have significant influence on the opinions of a largenumber of health care providers.6. Head nurses' knowledge regarding deinstitutionalization is notadequately utilized in the decision-making process.LimitationsThe participants' perceptions are applicable to patients within thehospital setting only.7The participants' perceptions reflect only those of the head nursesand not other nursing staff.The participants, graduates of schools of nursing both in Canada andabroad, have different clinical backgrounds and philosophies.The researcher cannot eliminate her personal views of thephenomenon but is aware of them.Significance of the StudyScientific SignificancePhenomenological research generates a description and deeperunderstanding of the phenomenon of interest.The findings of this study will contribute to nursing's body ofknowledge. Researchers will be able to select themes that emerge from thefindings and conduct further qualitative and or quantitative studies to buildon the present knowledge of the phenomenon. Further research on thefindings will add to the existing theoretical knowledge as "theoreticalknowledge in nursing is dependent on research" Brown (cited in Nicoll,1986, p. 12).Practical Significance Knowledge of the phenomenon of deinstitutionalization will increasethrough the documentation of perceptions of head nurses on the effect ofdeinstitutionalization on people with chronic mental illnesses. The findingsif communicated to other head nurses and levels of staff within the hospital,8will be useful in promoting better patient care. This knowledge will also behelpful in the identification and planning of discharge of patients to thecommunity, so that patients may be selected and placed appropriately.Placements should be based on the patients' needs. The findings of thestudy should facilitate an increase in communication and consultationbetween the head nurses and administration in the downsizing of thehospital and the deinstitutionalization process. In addition, the findings ofthe study may stimulate the head nurses and other staff to conduct furtherresearch within the hospital.SummaryThis chapter has provided the background and conceptualization ofthe problem which is the need to articulate head nurses' perceptions of theimpact of deinstitutionalization on persons with chronic mental illness. Adescription was given of the operational definition of terms, assumptions,limitations and significance of the study. In Chapter two will be presented areview of the selected literature. Chapter three will describe the researchdesign, sample selection and selection criteria, data collection, procedures,data analysis and ethical considerations. Chapter four will present thestudy's findings. Chapter five will present discussion of the findings. Lastly,Chapter six will discuss the summary, conclusions and implications fornursing practice, education, administration and recommendations forfurther research.9CHAPTER TWOLiterature ReviewIn the literature review, the historical perspective of deinstitu-tionalization, the impact of deinstitutionalization and the current status ofthe Canadian mental health care will be addressed. Such a review willassist the reader to understand the changes and progress made in the careof the chronically mentally ill over the years.Historical Perspective of DeinstitutionalizationAccording to Gralnick (1985) for some two hundred years, thementally ill in the United States lived in the community or with paupersand the physically ill in jails and almshouses under brutal and inhumaneconditions. In the mid nineteenth century Dorothea Dix started a crusade tochange the inhumane treatment of the mentally ill. Her efforts resulted inrapid growth in the number of state hospitals. Although the care providedvaried from acceptable to poor, the state hospital system flourished.From the middle of the last century to the middle of the twentiethcentury the emphasis in the treatment of the mentally ill was on custodialcare in large institutions. Usually, these institutions were located in ruralsettings away from urban centres which they served. The large institutionsfulfilled the function for society of keeping the mentally ill "out of sightthus out of mind." Then a shift in the modality of psychiatric care occurredas a result of several factors. One factor was public opinion formed by10"decades of public attack upon state mental hospitals in movies such as'The Snake Pit' and in books such as Albert Deutsch's 'The Shame of theStates', a scathing expose of the state hospitals that aroused great publicoutcry" (Gralnick, 1985, p. 738). Mental health professionals and thegeneral public had begun to question the philosophy and need for largemental hospitals. There was also public outcry about the expense of caringfor the chronically mentally ill and hospitals made efforts to cut costs ontheir treatment (Polcin, 1990; Talbot, 1988).Another factor was the emergence of the civil libertarian movementthat stressed individual rights. There were concerns that the mentally illwere becoming institutionalized. "The institutionalized being thoserelegated to the back wards who appeared to be deteriorating, had lostcontact with their families and communities and become apathetic to theirfate" (Crawford & Conacher, 1988, p. 14). From a humanitarian point ofview, it was thought that the chronically mentally ill patients would bebetter off in the community, as long hospitalizations in psychiatricinstitutions were seen as promoting chronicity. It was also thought that thementally ill would be optimally treated in an environment that permitscontact with the rest of society and with the mainstream social institutions.They would have closer contact with friends, family members and access toother resources. In addition, it was believed that "community care wouldprevent mental illness itsel' (Gralnick, 1985, p. 738).11The success of the major tranquilizers developed in the 1950's,particularly the phenothiazine, is another factor affectingdeinstitutionalization. The tranquilizers have resulted in a large proportionof the mentally ill gaining control of their "aberrant" behaviours to theextent that they have been able to function outside a structuredinstitutional setting (Crawford & Conacher, 1988).Another factor contributing to deinstitutionalization was the changein the commitment laws of the various states in the U.S.A. The law madethe involuntary commitment of psychiatric patients a more complex process.It became more difficult to hold psychiatric patients indefinitely inpsychiatric hospitals against their will. Thus an involuntary indefinitecommitment of patients to psychiatric hospitals became a thing of the past(Lamb, 1984).Not the least of the motivating factors was financial. According toLamb (1984) the state government wanted to shift some of the financialburden for the chronically mentally ill to federal and local government. Aidto the Disabled Act became available to the mentally ill in 1963 makingthem eligible for the first time for federal financial support in thecommunity. With this Act, psychiatric patients were able to supportthemselves or to be supported either at home or in facilities such asboarding houses or old hotels at little cost to the state. It was less expensive12to maintain patients in the community than in state hospitals thusdeinstitutionalization of the chronic mentally ill patients was encouraged.Impact of DeinstitutionalizationWhile deinstitutionalization has been a blessing for many patients,for thousands of chronically mentally ill patients and their families it hasbrought frustration, anguish and despair. These people have been trappedin a system in which neither the communities nor the hospitals can provideadequate care. "Families who sought help for their relatives in communitynursing and personal care homes found that they offer little more than aplace to live as adequate mental health care is not available in thesefacilities" (DuBois & Gates, 1990, p. 606).Homelessness is closely linked with deinstitutionalization in thesense that three to four decades ago most of the chronically mentally ill hada home in the state and provincial hospitals. Today, due todeinstitutionalization, many of the chronically mentally ill live on thestreets, under bridges and in "cheap, run-down" hotels and rooming houses(The Vancouver Sun, 1992).As a result of living on the streets, with little or no support system,most of these patients regress within a short time following discharge fromhospital. Their "strange behaviours", fear and disorganization often end inconflict with the law. They often assault others, perhaps to protectthemselves, or are assaulted by others. According to a report done by the13American Psychiatric Association task force, Lamb (1984) stated " ratherthan hospitalization and psychiatric treatment, the mentally ill often tendto be subject to inappropriate arrest and incarceration" (p. 905).Many chronically mentally ill people due to dysfunctional behaviours,decreased skills and lack of social support, experience unemployment andpoverty (Wolf & Fry, 1990). Their lack of money together with theirdecreased skill in money management make it difficult for them to sustaina social life (Jahoda, Cattermole & Markova, 1990). Sadly, unemploymentand poverty contribute to their emotional instability, loss of prestige,feelings of inferiority, expectation of failure and distrust of others. Hencemost chronically mentally ill fall "through the cracks" and or arerehospitalized.The stigma of mental illness is still evident amongst the public.Generally, society believes that the mentally ill are "dangerous" and willjeopardize the public's safety if they are "let loose" in the community.Attitudes have been influenced by movies such as "One Flew Over TheCuckoo's Nest" and from media headlines such as "Mother and TwoChildren attacked by Mentally Ill Patient" (The Province, 1988). Residentsand property owners reject the mentally ill and protest against governmentplans to build psychiatric facilities in some communities, for example WestVancouver. Unfortunately, society remains hostile to this population. Thisattitude is reflected in the articles that appear in the local newspapers14entitled "World a Lonely Place for the Mentally Ill", West Vancouver takesup petition against Boarding Home for the Mentally Ill" (Vancouver Sun,1990).On the other hand, some chronically mentally ill individuals foundcommunity life much better than living in an institution. They adjusted totheir new living situation and perceived their lives as improved according tothe findings of a research study done by Okin, Dolnick & Pearsall (1983).This research was carried out in Massachusette between 1978 and 1981.The researchers interviewed thirty-one patients in the experimental groupand ten in the control group. The experimental group was patients whowere discharged to residential settings with a goal of maximizing personalindependence and developing the necessary repertoire of skills for successfulcommunity adjustment. The control group was patients who remained inthe hospital setting. The community residential program was supplementedwith affiliated day services such as drop-in social clubs, treatment programsand sheltered workshops. The state hospital provided less than adequateprivacy and little opportunity for tailoring treatment to the needs ofindividual patients in the control group.Three different data collection techniques were used in this study.They were case record abstract, patient interviews and staff ratings.Unfortunately the same staff members did not complete the rating scales oneach patient at all three points in time, a fact, according to the researchers15that may have introduced some unreliability into the data. Also, the samplewas small, especially the control group. Although the findings showed thatsome patients preferred and adapted well to community living, the findingscannot be generalized to all chronically mentally ill. However, with furtherresearch it may be possible to show that with adequate services andfacilities the chronically mentally ill could adapt to the mainstream ofsociety.Friedlob, Janis & Deets-Aron, (1986) assessed a program that focusedon developing patient competence in daily living skills in health andhygiene, nutrition, household management, budgeting, interpersonalrelationships, community resources, leisure activities and occupationaltraining. Nineteen patients met the criteria for joining this program. Thesample group had intensive help and training from two occupationaltherapists who developed the program.Five years after treatment, twelve of the nineteen patients remainedin the community. Eight of the nineteen patients had no rehospitalizationswhilst four patients had multiple rehospitalizations. Of those rehospitalized,the hospitalization period decreased from a three to six month period to atwo to four week period. For the majority of the chronic patients in thisstudy the quality of community life improved in terms of livingenvironment, occupational behaviour and length of rehospitalization.16Again, the sample size in this study was too small to generalize thefindings. The sample consisted of high functioning patients who wereemployed, employable and responsible for self medication. These patientswere motivated and with intensive follow-up, the chances of success weregreater than if they had not been motivated. In addition, the diagnosesamong the sample varied from schizophrenia, depression, manic-depression,personality disorder and anxiety neurosis. In this investigator's opinionperhaps the findings would be different if the sample consisted of peoplewith only personality disorders or schizophrenia. However, the literatureindicates that deinstitutionalization has affected the chronically mentally illpopulation in different ways.Current Status of the Canadian Mental Health SystemEpp (Health & Welfare, 1988) stated that mental health issues haveprofound implications for all aspects of human existence. It is not only aconcern for professionals but all of society has a stake in mental healthissues and a contribution to make. Mental health promotion in Canada is achallenge that requires the employment of a diversity of talents, resourcesand strategies. In addition it must be looked at on several levels. Epp (1988)states "deinstitutionalization has rarely been followed through in aconsistent and logical way" (p. 20). He outlines seven guiding principles fordevelopment of public policies that support mental health. The sevenprinciples are "human rights and citizenship, mutual aid and voluntary17service, consumer participation, professional participation, the strength ofcommunities, knowledge development and policy coordination" (Epp, 1988,p. 18).According to Epp (1988) the principle of strengthening communitiesmeans having balanced allocation of resources to enable communities todevelop programs and services to help individuals with mental healthproblems and their caregivers. This process involves community consensusof values, principles and strategies that govern policies for communitymental health.The Canadian Nurses Association (1991) outlines five significantcriteria in Canada's mental health care system which are related to theWorld Health Organization of primary health care. These criteria are"accessibility, public participation, promotion of health and prevention,intersectional cooperation and appropriate technology" (C.N.A. 1991, p. 5).In an attempt to solve these problems in British Columbia, especially withthe downsizing of the provincial psychiatric institution, the Ministry ofHealth has adopted five important "service principles" to provide qualityservices to the mentally ill. These principles are "comprehensiveness,coordination of care, continuity of care, availability, accessibility andaccountability" (Ministry of Health, 1987, p. 3).Head nurses in mental health services are in a critical position toinfluence care. Pearlmutter (1985) states that "head nurses have a18cooperative collaborative relationship with members of other disciplines whoalso network closely with clients" (p. 56). Head nurses at the provincialpsychiatric institution in British Columbia are concerned about thepromotion of optimal mental health not only for their patients but forfamilies, the community and society. They are actively involved with thetreatment and rehabilitation of their patients. Head nurses at theprovincial hospital, due to their pivotal role, liaise with professionals andnon professionals both within the hospital and in the community in relationto patient care. They are also advocates on behalf of the patients and worktowards the success of deinstitutionalization of their chronic mentally illpatients.Some authors (Long, Mackle & Monaghan, 1989; Friedlob, Janis &Deets-Aron, 1986) are in favour of deinstitutionalization while others claimthat the care provided in the community does not meet the needs of thechronic mentally ill (Aviram, 1990; Bachrach, 1984). Aviram (1990) pointsout that "some of the mental health service system problems are related tosocial and political factors and fluctuating support for mental healthservices which traditionally has had to compete with other social welfareand medical programs" (p. 71).From the literature review, it becomes apparent that there is a needfor the improvement of community services but also there is a need forinstitutional care for some chronically mentally ill people. In addition, to19improve the services already in existence by decreasing fragmentation ofservices, more collaboration is required among the key players such asgovernment, hospital and community to successfully deinstitutionalize thechronically mentally ill.In Canada, particularly in British Columbia, deinstitutionalization ofthe chronically mentally ill is progressing steadily. As stated in theliterature review, the Federal Government as well as the ProvincialGovernment have implemented policies and guiding principles for theimplementation of deinstitutionalization. Emphasis is placed on communitycare such as boarding homes, personal care homes for the chronicallymentally ill to prevent rehospitalization and to facilitate the downsizing orclosure of large institutions. However, the community resources andfacilities are less than adequate to cope with the growing needs of thispopulation.In summary, most of the research on deinstitutionalization isconducted by disciplines other than nursing. Since head nurses inpsychiatric hospitals are clinically involved with deinstitutionalization andits repercussions or sequelae, it is therefore, important to conduct a study togather a thorough understanding of their perceptions of the impact ofdeinstitutionalization on the chronically mentally ill.20SummaryIn order to establish what is known about the impact of deinstitu-tionalization on persons with chronic mental illness, in this chapter isreviewed selected literature related to the historical perspective ofdeinstitutionalization, the impact of deinstitutionalization and the currentstatus of the Canadian mental health system.21CHAPTER THREEMethodsThis chapter describes the application of the phenomenologicalmethod of inquiry in a study of the head nurses' perceptions of the impact ofdeinstitutionalization on persons with a chronic mental illness. Theimplementation of phenomenology is discussed in relation to sampleselection and selection criteria, data collection, data analysis and ethicalconsiderations.Research DesignA phenomenological approach of qualitative research was the selectedmethod used to answer the study's research question. "The phenomeno-logical approach is primarily an attempt to understand empirical mattersfrom the perspective of those being studied" (Munhall & Oiler, 1986, p. 89).According to Ornery (1983) the goal of the phenomenological method is toprovide an accurate description of the phenomenon under study.Head nurses at a large psychiatric hospital in Western Canada arepresently involved with deinstitutionalization of the chronically mentally illand are best able to speak to the nurses' perspective of this phenomenon.They see the effects of deinstitutionalization on a daily basis in the clinicalarea. Their knowledge regarding deinstitutionalization is gained throughyears of working with the chronically mentally ill and in theimplementation of the phenomenon. It is the participant's point of view that22provides the "rich data which must be obtained" (Giorgi, 1975a, p. 100).Sample Selection and Selection CriteriaThe participants in a phenomenological study must have lived or beliving the experience under investigation. Also they have to be interested inunderstanding and expressing the feelings which accompanied theirexperience. The sample for this study was selected by the investigatorthrough purposive sampling. Purposive sampling according to Woods andCatanzaro (1988) is a process in which the investigator selects the casesbased on a judgement of the extent to which the potential participants willbe most representative of the phenomenon under study. In this study theinvestigator selected as subjects eight head nurses from a provincialpsychiatric hospital in Western Canada who have been in charge of thefourteen wards in the continuing treatment program and in the acuteassessment and treatment program. These two programs were more activein receiving new admissions and discharging patients to the community.Hence the head nurses in these programs were more involved with thedeinstitutionalization process.The inclusion criteria for the subjects were (1) they had to be headnurses, and (2) had to be employed at the hospital for a minimum of fiveyears. Since the hospital had been in a downsizing phase for the past fouryears, the head nurses had a minimum of four years experience with thedeinstitutionalization process. First, the investigator wrote a letter to the23Vice President of Nursing Services at the hospital requesting her to seekpermission (Appendix A) from the selected head nurses to be approached bythe investigator.The Vice President telephoned the investigator stating that she hadgiven a copy of the letter to the head nurses of the respective programs.With the head nurses permission she also gave the investigator permissionto contact the head nurses. One head nurse from the continuing treatmentprogram phoned the investigator to volunteer as a participant for the study.The investigator phoned the head nurses in the acute assessment andtreatment program who met the sampling criteria. Four head nurses fromthat program volunteered to participate. The investigator then phoned threehead nurses from the continuing treatment program who volunteered to besubjects for the study. Ethical procedures were followed as indicated inAppendix A and ethical considerations, p. 34.Data Collection ProceduresThe interview technique is frequently used in phenomenology. Theresearcher needs the skill to be a good listener and know how to encouragepeople to describe their feelings. In order to answer the research question inthis study, the data collection process consisted of two face-to-face interviewswith each head nurses.The interviews were conducted in an area convenient to the headnurses. Though the investigator preferred to interview the head nurses24away from their work environment, the head nurses felt that their offices atwork were convenient and provided the necessary privacy.The investigator used five trigger questions (Appendix C) to facilitateexploration of the research question during the first interviews. The triggerquestions were open-ended questions that evolved from the literaturereview. For example, what are the benefits of deinstitutionalization for yourpatients? Open-ended questions are designed to create a conversationalatmosphere and allow for free expression (Van Maanen, 1983).Additional questions were asked during the first interview to eitherclarify what the participant said or to further the investigator'sunderstanding of what was being discussed.The content of the second interview was drawn from an analysis ofthe material discussed during the first interview. The investigator clarifiedareas that were unclear and verified emerging themes consistent withColaizzi's phenomenological methods as outlined by Reimen (cited inMunhall and Oiler, 1986, p. 94-95).For accurate verbatim accounts of the participants' responses theinterviews were tape- recorded. None of the participants indicated that thepresence of the tape recorder hindering their ability to speak freely. One ofthe participants requested that the tape recorder be turned off whilethinking through the responses to each question. The tapes weretranscribed verbatim by the investigator. After transcription, the researcher25analyzed the interview data. She interviewed seven of the eight potentialsubjects for the study as no new information was forthcoming after theseven interviews.Data AnalysisThe processes of collecting, coding and analysing data were continueduntil data collection was complete. Then the final stage of analysis became"a period for bringing final order to previously developed ideas" (Lofland &Lofland, 1984, p. 131).The investigator analyzed the data using Colaizzi's phenomenologicalmethods as outlined by Reimen (cited in Munhall and Oiler, 1986, p. 94-95).The procedural steps were as follows:1. All tape-recorded interviews were transcribed verbatim by theresearcher. Each interview was then read through twice to acquire afeeling for them.2. Then the transcript was read again to extract significant statementsthat directly pertained to the phenomenon under study. Theresearcher underlined the significant statements from eachdescription, phrase and statement.3.^From the significant statements meaning units were identified. Theresearcher wrote the meaning units in the margin of the transcripttext. Then the researcher reflected upon the meaning units to ensurethere was a connection with the original description.264.^From the meaning units the researcher developed a cluster of themes.Forty seven themes emerged from the meaning units that werecommon to all the participants' descriptions. Examples of themeswere; unplanned discharges, non-compliance, lack of communication,revolving door syndrome, patients' rights, patient rehabilitation,individuality and normal environment. Next the researcher referredback to the original descriptions to validate the themes.At the second interviews the researcher explained to each participantwhat was being done with the data collected and sought clarification andverification of the themes. Some of the subjects could not believe how"lengthy" their transcripts were. None of the participants disagreed withthe beginning analysis of the data. Comments such as "exactly" and "righton" were expressed. Three of the participants requested "to look at" thecompleted thesis. During the second interview further clarification andelaboration of data occurred which assisted the researcher to ask pertinentquestions about the phenomenon under study. The second interviews weretape-recorded, transcribed and analyzed in the same way as the first.Themes developed from the data were further condensed into three contentcategories. A diagram depicting the final conceptualization of thephenomenon is shown in Figure 1, p. 32. Next the researcher integrated andsynthesized the essential themes to develop an exhaustive description of the27phenomenon. The investigator implemented the validation process asnecessary throughout the data analysis process.The analysis concluded with an exhaustive description of the headnurses' perceptions of the impact of deinstitutionalization on the chronicallymentally ill.Ethical ConsiderationsTo protect the rights of the study participants, this research proposalwas approved by the University of British Columbia's Sciences ScreeningCommittee for Research and Other Studies Involving Human Subjects andthe hospital's research committee.The participants were informed verbally and in writing of thepurpose, the benefit and the risk of the study to enable them to makeinformed consent. They were also informed of the expected time needed todevote to the study. The participants were told that they faced no risks fromthe study. They had the right to withdraw from the study at any timewithout implications to them personally, to their employment or to thehospital. Written consent (Appendix B) was obtained from each participantbefore commencement of the first interview and for tape recording of theinterviews.The information provided was shared by the researcher's thesiscommittee but was kept confidential from all others. To maintainanonymity, the participants' names did not appear on any of the materials.28Tape recordings were kept at the researcher's home. Upon completion of thestudy the tapes were destroyed. During the interviews participants privacywas maintained as all interviews were conducted in their private offices atwork.SummaryIn this chapter the phenomenological method was discussed. Datawere collected through fourteen interviews with seven head nursesemployed at a large psychiatric hospital in Western Canada who wereinvolved with the deinstitutionalization of the chronically mentally ill.Sample selection was by a purposive sampling technique. Five open-endedtrigger questions were used as a guide for the interviews with theparticipants. Their rights in terms of informed consent, confidentiality andanonymity were safeguarded throughout the research process. Data analysiswas concluded using Colaizzi's phenomenological methods.29CHAPTER FOURPresentation of FindingsThe accounts given by the seven participating head nurses of theirperceptions of deinstitutionalization of the chronically mentally ill will bepresented in this chapter. The chapter begins with a description of theparticipants in the study. Next is an introduction of the conceptualization ofdeinstitutionalization formed from concepts derived from the data. Then thepresentation of the participants' account of their perceptions organizedaccording to the developed framework will be presented. The three contentcategories are: contributing factors, impact on the individual andfacilitating factors. Deinstitutionalization is affected by each category.What is the head nurses' perception of the impact ofdeinstitutionalization on persons with a chronic mental illness? Theaccounts given by the seven participating head nurses of their perceptionsof deinstitutionalization of the chronic mentally ill will be presented in thischapter.Description of the ParticipantsThe seven participants in the study were all employed at a largepsychiatric hospital in Western Canada as head nurses in charge of wardsin the acute assessment and treatment unit or in the continuing treatmentunit. They had worked at this hospital for a minimum of nineteen years inpositions such as staff nurse, assistant head nurse and currently as head30nurse. They participated in different committees such as the standardscommittee, quality assurance and risk management committee, procedurecommittee, policy committee, nursing service committee and planningcommittee. One of the head nurses was the coordinator of the bridgingprogram whilst another was the chairperson of a planning committeeinvolved with downsizing.Four of the seven participants obtained their basic nursing education(R.P. N/R.N) in England whilst the remaining three studied in Canada.Each participant had a minimum of twenty years experience working withthe chronic mentally ill population. In addition, as head nurses they hadbeen in charge of wards, other than their present ones, in which theprogram was different, for example, organic brain syndrome and long termrehabilitation.Conceptualization of the DataThe purpose of this study was to present data which will enhance ourunderstanding of the head nurses' perceptions of the impact ofdeinstitutionalization of the chronically mentally ill. Meaning units wereidentified from the significant statements in the transcripts. Examples ofmeaning units were patient involvement in planning, discussions with theteam about discharge, we give the patient choices in placement, we tellthem about resources available and we ask their opinions. From themeaning units, forty seven themes were extracted. Examples of themes31were patient participation, patient choice, patient needs, discharge planningand appropriate facilities. The forty seven themes were further condensedinto three major content categories: (1) Contributing factors (2) Impact onthe individual (3) Facilitating factors (Figure 1).The themes placed under the content category: contributing factors,were, hospital mandate to downsize, mental health act, and consumeradvocacy. Themes under the content castegory; impact on the individualwere stigma, homelessness, revolving door syndrome and quality of life.Communication, patient preparation, education and resources/facilities werethemes placed under the content category: facilitating factors. Thepresentation of the head nurses' accounts in the three major contentcategories will allow the reader to follow how deinstitutionalization has animpact on the chronically mentally ill.Contributing FactorsConcepts in the contributing factors category will now be described.Verbatim accounts from the participants will be used for illustrativepurposes and to support the concepts derived from the data. Theabbreviations used in this chapter to identify the participants are H/N: head32Fig 1. Conceptualization of Deinstitutionalizationof the Chronically Mentally Ill33nurse and R: researcher. Names of individuals mentioned in the text of theinterviews identified as Mr.X or Ms.X.Hospital Mandate to Downsize This hospital is actively pursuing its mandate to reduce the presentbed count to a three hundred bed hospital. The head nurses referred to thisprocess as "downsizing." Three of the head nurses stated that downsizingwas the "buzz word" used in the hospital. Another head nurse called it "thecurrent theme." The head nurses generally felt that if downsizing were"clinically driven" whereby the patients needs were taken into account,then it would be beneficial to the patient. For example, patients would beappropriately placed where their individual needs would be met. If howeverdownsizing was "financially driven" then the patients would be at adisadvantage because they would be discharged without adequatepreparations made to meet their needs in the community.R:^What would be some of your concerns regarding the patients inthis process?H/N: My basic concern, probably the concern of many others, is thattheir needs as individuals may be overlooked in thisprocess. That is a major concern. Beyond that is the concernfor the development of necessary facilities and supports thatthese people will need if they are moving from the hospital tothe larger community.34H/N: It is too financially driven. I am not saying that no thought isgiven to what is needed for The client but the main thought isfinancially what are we going to benefit. Because that is themain focus, we are not really thinking of what is needed forthat client prior to being deinstitutionalized, what skills dothey need to live in the community properly like a normalperson. The feeling among the head nurses was that down-sizing was a progressive step in the treatment of the chronicmentally ill. To be effective, it should be a gradual, wellplanned process "in which the patient is the focus."H/N: We have to guard against over-exuberance in this downsizing.We have to remember the patients' care and needs areprimary. If it fits into the downsizing plan of the hospital, fine.If it does not, we have to remember the key issue here anddownsizing will not be the key issue for the patient who is notready yet.H/N: I think we have to be proactive and not reactive in these fastmoving times. If we are going to close beds in this hospital thatit is done for the total betterment of the patients, not theopposite.H/N: As we are under pressure to downsize we try to get thepatients out as soon as possible.35The head nurses expressed a feeling that not all the patients wereable or suitable to be discharged. Some patients have been institutionalizedfor many years. Due to the chronicity of their illness and theinappropriateness of their behaviour would require "institution" or"asylum" type of care. The head nurses felt that the need for an institutionshould be taken into account in the downsizing process.H/N: I am quite certain that the goal of three hundred beds isunrealistic. Three hundred beds are not very many. It looks asthough there are about four hundred patients who needs"asylum" and the new hospital is only supposed to be threehundred beds. The planning for the new hospital came beforethe patient needs assessment. It should have been the otherway around. So I've got some big concerns about that. I thinkthree hundred beds is far too ambitious.Mental Health ActThe head nurses also described how the mental health act affects thedeinstitutionalization process of the chronic mentally ill. Patients admittedon an informal status (patient agreed to be admitted without signed medicalcertificate) could discharge themselves at any time. Doctors changed thepatients status from involuntary (patient admitted with two signed medicalcertificates) to "informal" as soon as there were clinical signs ofimprovement. Head nurses could not prevent an "informal" patient from36leaving whether the head nurses felt he/she was fully recovered or not.Patients were also discharged through the review panel which is anindependent review board for patients. The head nurses felt that those"unplanned discharges" had an impact on the way the patients functionedfollowing discharge.H/N: Patients have a choice of leaving hospital when theircertification runs out. This interferes with their preparation.Another way they leave is by going through the review panel.H/N: Patients who come in certified are decertified as soon as theacute stage is over. Some of the informal patients when theydecide to discharge themselves, legally there is not much wecan do to stop them. So in terms of discharge planning, follow-up etc. is a questionable aspect.H/N: We have not sent anybody out that didn't have well preparedplans to go. The only exception to that are the ones who go onunauthorized absence. They are dropped from the count which Isuppose is the downsizing in itself but not the preferable onethat we have planned.Two head nurses felt that the mental health act of 1979 had apositive impact on their patients. The mental health act allows their"informal" patients more freedom whilst hospitalized to go out bythemselves shopping and visiting in the community. These were37opportunities they did not have in past years where involuntary patientshad to be accompanied outside the hospital by staff or family and thoseoccasions were not often.H/N: Patients demand to go out on day pass, especially in ourprogram where we encourage them to go out for week ends. Ifthey are certified that would cause trouble. If a patient iscertified he cannot go out on day pass or visit leave by himself.He would need someone responsible to come in and at leastverbally say that he'll look after the patient while he is outthere. So for many programs especially in this division,decertification is a better way to deal with patients going inand out, for visit leave and day pass etc.The mental health act also affects the care that patients receive inthe community. According to the head nurses, patients who had unplanneddischarges had no follow-up plans made for continued care in thecommunity to help them function. If and when their condition deterioratedand required treatment, doctors were reluctant to certify patients to receivecare. Also if the patient was not certifiable he/she had the right to refusetreatment. In addition, according to one head nurse it was more difficult toadmit patients directly to that hospital. All admissions had to go throughthe general practitioner and the general hospital.38H/N: In my opinion even though the mental health act is there forthe good of the patients, it is hindering them in the sense thata lot of patients are not well enough to make informeddecisions.H/N: In the past when we discharge patients we anticipate somedifficulty may be because of their past history. We put thepatient on visit leave and then extended leave before he/she isactually discharged. By doing so the patient and thecommunity workers have a kind of security that anything goeswrong the patient can come back right away. We don't havethat extended leave anymore. If anything goes wrong, theycannot get back in. They have to go through the G.P and to thegeneral hospital. Once they are decertified they have to becertifiable to be committed to hospital again.H/N:^With the mental health act it is very difficult to demand, withall the patient empowerment, you cannot say you have to havethese treatment or skills.Consumer AdvocacyThe head nurses stated that consumer advocacy and patient rightshave given patients more involvement and choice in their care andtreatment which have had an impact on the deinstitutionalization process.If patients disagree with their treatment for example, they have the right to39refuse or to lobby for change. In past years, opportunities for questioningtheir care or to have choices in their care were not available as they aretoday. If patients were dissatisfied they did not have advocacy groups or anOmbudsman to approach for support. Patients at this hospital have directaccess to an Ombudsman with whom they can discuss their concerns andknow that action will take place. They also have a patients' concerncommittee in the hospital where they discuss patient issues. Pertinentconcerns are taken to the hospital administration for further action ifwarranted. Therefore, if patients are unhappy with their treatment ordischarge plans in the hospital, pressure from consumer advocacy groupsand/or the Ombudsman contribute to their early discharge. However,patients who are not stable soon deteriorate in the community and arerehospitalized.H/N:^Another point is the legal matters. The patient has theopportunity now that they never had in institutional settingbefore to discuss with the Ombudsman some concerns theyhave. They have the opportunity to discuss with the patients'advocate that they didn't have before.H/N:^The patients also have another thing that is part of deinstitu-tionalization and positive. That is they have their owncommittee, patient concern committee. They get to attend. Anexample is the new chief executive officer of this hospital, she40attended one of those patient concerns committee not that longago. It shows the credence that the administration put in theconcern of patients. I think that is a valid issue that is a highpriority these days, it wasn't before.The head nurses also described the presence of consumers and familymembers representing the patients on planning committees in the hospitalas valuable to the deinstitutionalization process. Advocacy from familymembers and patients allowed the patients more involvement in decidingtheir own care. In addition health care providers have become moreaccountable for their actions to family members and patients.H/N: It also involves the families and in my two teams I've gotconsumers. The families are able to give input as to what theysee as lacking. It involves consumers, who are better able tosay what they need as the person who had the experience. Itgives the consumers a form of independence to say my wordmeans something, what I say is valued.In summary the deinstitutionalization of the chronically mentally illfrom this hospital is the result of a mandate from the provincialgovernment to reduce the patient population from nine hundred to threehundred within the next few years. Contributing to this process is themental health act which facilitates informal patients to dischargethemselves without follow-up plans for treatment. That also applies to41patients discharged through the review panel and unauthorized absence. Inaddition consumer advocacy and patient rights give the patients more voicein their treatment which contributed to an accelleration of thedeinstitutionalization process.Impact on the IndividualThe effects of deinstitutionalization on the individual described by thehead nurses include: stigma, homelessness, revolving door syndrome andquality of life.StigmaThree of the head nurses felt that the patients are stigmatized in thecommunity as patients were not allowed to reside in some neighbourhoods.11/N: Then suddenly there is a mini boarding house put up next tothem and that's when you see people picketing about this kindof stuff, "not my backyard; Oh yes, they've to go back to thecommunity but don't put them next to me."The community does not understand the nature of the patient'sillness. Hence, behaviours which might have been appropriate for thepatient, could be misinterpreted in a negative way by the community.H/N: Yes. There is an idea or feeling that patients are violent, so ifthey are assertive and it's not appropriate this can be scary topeople. It can be misconstrued as anger instead ofassertiveness. Patients are not always able to express their42assertiveness in the way we would like them to do. In thecommunity that would create anxiety. They wouldn't knowthat it is part of the illness.The head nurses also felt that the patients often lacked self esteem inthe community more so if they were unable to work or to participate inactivities.H/N: I think the patients need a sense of purpose, where they cantrain and also work to enhance their welfare or handicappension and they should be allowed to earn more than whatthey are making right now. So it will give them increased selfesteem. Along with job training, make some jobs available andthat will help patients remain in the community.H/N: Most normal people have jobs or they go to school to developskills. These things are needed in order for them to livenormally.Homelessness All the head nurses identified homelessness as an effect of thedeinstitutionalization of the chronically mentally ill. Patients weregenerally poor, unemployed and could not pay for reasonable housing. Alsosome patients were not accepted in affordable boarding homes because oftheir "reputation" or they did not like to live in boarding homes. In addition43there is a shortage of living accommodation for those patients in thecommunity.H/N: We see people sleeping in doorways and in cardboard boxes. Wewatch T.V or we walk down to Vancouver now and you seepeople whose needs are not being met.H/N: We also see more and more sick people out there on the street.1-1/N: Yes. It seems more and more patients are out there nowbecause of this process. Actually the biggest thing for them ishousing. They have no place to stay, so they end up in skid rowand even on the streets.Revolving Door Syndrome All the head nurses stated "the revolving door syndrome" is a resultof deinstitutionalization. Non- compliance with medications and follow-upcare result in exacerbation of illness thus requiring rehospitalization. Thechronicity of patient illnesses also adds to the revolving door syndrome.H/N: As you know we see the same thing - stop taking medication -I'm feeling good, I'm alright now, I won't take my medicationsanymore. They decompensate quickly and back they come.H/N: Some of them may have gone through the revolving doorsyndrome many times.H/N: That's been proven over and over again because we have whatwe call the revolving door syndrome.44H/N: We end up with the revolving door, they go out and come backand still don't have skills.Quality of Life Though deinstitutionalization has negative effects on patients, it alsohas positive effects for some patients. The head nurses suggested thatdeinstitutionalization can provide a better quality of life in "a normalenvironment" for patients who can "make it in the community." A betterquality of life means that the patients regain "dignity", "privacy" and"independence" which they do not have in the hospital. They can beindividuals and do whatever they want to do in their own time as opposedto fitting into a routine in the hospital.H/N: I think the benefit is that it really allows them some type ofindividuality I really do. I think when patients are in hospitalor have been hospitalized a long time a lot of theirindependence is taken away.H/N: Benefits - a normal environment and hopefully the patientswill progress to independent living. There is more self esteemand personal growth.H/N: Deinstitutionalization brings about a better quality of life forthe patient. It is nice that they can say "I want to watchhockey tonight instead of someone else tuning on a program45and everyone watches it. Individuality is one of the greatestbenefits of deinstitutionalization.II/N: Getting back into their own communities where they will benot only among families but also among their friends whomthey grew up with.In summary, the effects of deinstitutionalization of the chronicallymentally ill has negative and positive effects. The negative effects describedby the head nurses are stigma contributed, for example, by chronicity andlack of understanding of the illness. Homelessness associated with povertyand lack of adequate affordable housing is also a negative effect. Non-compliance with medication and treatment plan contributes to the revolvingdoor syndrome. However, improved quality of life was described as apositive effect of deinstitutionalization. Living in the community gave thepatients independence, individuality and personal growth.Facilitating FactorsThe head nurses described factors that can facilitate the success ofdeinstitutionalization of the chronically mentally ill. These factors werecommunication, patient preparation, education and resources/facilities.These factors facilitate deinstitutionalization both in the hospital and in thecommunity. For example, if the resources are available within the hospitalto adequately rehabilitate the patient prior to discharge and resources arein place in the community to maintain the patients present level of46functioning, then the patients chances of "making it" in the community arebetter.CommunicationGenerally the head nurses described communication between theadministrators in the hospital and themselves as an important factor in thedecision-making process regarding deinstitutionalization. They feel thatwith their knowledge and the clinical expertise about the care of thechronically mentally ill, they can provide constructive input concerningpatient needs, patient selection for discharge and resources appropriate forpatient level of function to facilitate the success of deinstitutionalization.However, in past years major decisions were made affecting patient carewithout the head nurses input, resulting in inappropriate placements withinthe hospital and discharges to the community. Most times, the patients areaffected if their needs cannot be adequately met. For example, if a patientrequires increased nursing supervision is discharged to a facility that doesnot have adequate staff to provide the care necessary to maintain thepatient's level of functioning, that patient will deteriorate. Eventually thepatient will be rehospitalized. Therefore, according to the head nurses,decisions such as those can be avoided with better communication betweenthe administrators and themselves.H/N: A ward in the continuing treatment program was ratherprecipitously closed. This was an action that we within the47program had no input into and were not able to influence inany other way other than responding to a directive. This is thechosen area, it will close, now you must do it.H/N: There again most of the time as a head nurse, quite often incertain programs you get the information at the last minute. Imay get told the same day they are closing down the program.From experience and talking with other head nurses, most ofthem would have similar experiences.Within the last year the communication in the hospital has improved "alead in the right direction." The head nurses now have more clinical inputinto the downsizing process.R:^Have you got much input into what's taking place?H/N: Not on a hospital-wide level but certainly within this ward andin this division. I've got a say in the way our division takesshape to meet the changing needs of the hospital. So from thatperspective I have input.11/N: The opportunity to give your opinion is there if you want it.H/N: To a certain extent our voices seem to be heard now more thanbefore. There is a change in management, pressure from thecommunity and may be political too. So more and more headnurses are speaking their minds.48On the other hand, though they have opportunities forcommunication and input, the head nurses remain sceptical. They questionwhether their input is utilized above their level in the hospital organizationin affecting the deinstitutionalization process.H/N: I am sitting on a committee that is involved with thedownsizing of the hospital. As a head nurse, I would like tothink that I have some influence in helping seniormanagement.H/N: I am on a number of committees and if the opportunities occurI do not hesitate to give my two bits worth. Let's hope they'lllisten to us. I just hope they'll listen to some common sense.Most head nurses feel that communication between the hospital andcommunity regarding the deinstitutionalization process has also improvedin the last year. In past years the hospital and the community functioned"as separate entities." They feel it is important "to work together" toprepare the community for deinstitutionalization of the patients.H/N: I feel strongly that the hospital and the community have towork hand in hand in communicating and planning for thesame goal.H/N: Another thing we can do as a group apart from theadministrators is to get the patient groups, communityresource workers, community agencies, the professionals in49here as well the consumers and their relatives to actually mapout and plan the best steps. Also include the mental healthteams and B.0 housing.H/N: I see communication between hospital and communityhappening somewhat now with the bed reduction program. ButI still see a lot of territorialism.Patient PreparationAll the head nurses described patient preparation to be "a vitalcomponent" in the discharge planning of the chronically mentally ill to thecommunity. In order for the patients "to make it" "to be successful out therein the community", they must be prepared with coping skills such as dailyliving and socialization skills.H/N: We are a social learning program. We have eight differentmodules in terms of life skills. We have personal care, stressmanagement, anger management, social communication,medication and sexuality. If the patient goes to all the classeshe should be well prepared.H/N: Just the skills of normal everyday living for example, where toobtain things, how to get to places, being independent.11/N: First of all, patients come into this ward and take part in basicprograms like news and views, socialization type activitieswhere they do hands on things. Patients are involved in50talking to each other, talking to staff. When they get used tothat type of things, progressively we get them involved in morechallenging programs such as community preparation skillsprograms which involve bus training, vocational information,leisure skills information and how to handle hostility both inhospital and in the community. They actually go out into thecommunity socialization to club houses, local places of interest.EducationThree head nurses described patient and community education aboutmental illness as an important factor in the deinstitutionalization process.For example, patients would be able to manage better if they couldrecognize signs and symptoms of their illness and seek help when indicated.The community might be able to support the patients by accepting them ifthey were knowledgeable about the patients' illness.H/N: I would say teach the resources, about their own symptoms,things that trigger their own decompensation, how to recognizeit, know when to go to the doctor and where to go for follow-up.H/N: We want to know if the patient shows some positive signs ofunderstanding the importance of follow-up with medications,follow-up visits with the mental health centres.Community education about mental illness is necessary for thepatients to receive appropriate care in the community. However, according51to three of the head nurses, community education on mental illness is"lacking."H/N: It is not only our job to prepare the individual patient butcitizens of the community have to know about mental illnesstoo.H/N: In terms of public education I think that is still lacking insome areas. Most people outside don't know what kind ofclients we have in here and what type of treatment we offer.Resources and Facilities According to all the head nurses another important factor affectingthe success of deinstitutionalization of the chronically mentally ill is thelack of resources and facilities. To meet the needs of the patients, theresources should be available, prior to discharge, to prevent "the revolvingdoor syndrome" and "patients falling through the cracks."H/N: I think No.1 you've got to have personnel in place that have agood understanding of both institution and the community andthen bridge that gap as effectively as possible.H/N: The nursing care in hospital is much higher as we have a lot ofqualified staff. Everyone knows in the boarding homes thereare very few professional staff.H/N: We know the resources are limited because we get all thereports from the social workers who visit the boarding homes.52We know the staffing is not satisfactory to fully and adequatelymeet the needs of the patients.H/N: Services apart from housing would be places where dischargedpatients could go to meet other people, such as day hospitals,clubhouses, drop-in centres, sheltered workshops, programs onjob training, jobs for discharged patients and other varioussupport services, increased staffing levels in the community.In summary a description of the head nurses' accounts of the impactof the facilitating factors on the deinstitutionalization process waspresented. The four factors communication, patient preparation, educationand resources/facilities are important and necessary to meet the needs ofthe chronic mentally ill following discharge from hospital to community.SummaryThe contributing factors, the impact on the individual and thefacilitating factors affect the deinstitutionalization of the chronicallymentally ill. One of the contributing factors for deinstitutionalization is thehospital's mandate to downsize the patient population from nine hundred tothree hundred patients. The general feeling is that downsizing is aprogressive step in the patients' treatment providing the process is wellplanned, gradual and has the patients' needs as the focus.The mental health act contributes to the deinstitutionalizationprocess by facilitating the quick discharge of patients. Some of those53discharges came as a result of the review panel's decision, throughunauthorized absence or by patients' discharge of themselves. Unfortunatelythose patients follow-up care was affected. The mental health act also gavethe patients more freedom to socialize outside of the institution and tobecome more community-oriented.The consumer advocacy movement had improved in the hospital inrecent years. For example, the patients have a patient concern committeewhich the administration supports. Due to consumer advocacy, the patientshave direct access to an Ombudsman, an opportunity they did notpreviously have. Generally the patients have more rights, choices andrepresentations regarding their treatment than they had in past years.In the content category, the impact on the individual, stigma,homelessness and the revolving door syndrome were identified as negativeeffects of deinstitutionalization. The community's lack of educationregarding mental illness and the patient's chronicity of illness contributedto the stigmatization of the patients. Inadequate housing, job opportunitiesand poverty resulted in homelessness for the chronically mentally ill in thecommunity. In addition, the deinstitutionalization process also results in therevolving door syndrome mainly due to non-compliance with treatment.Lastly how the facilitating factors of communication, patientpreparation, education and resources/facilities affect the deinstitu-tionalization process was described. There had been no communication54between the administrators and the head nurses regarding downsizing inthe past. Decisions were made to close wards/programs without clinicalinput from the head nurses. Though they recently have input to someextent, the head nurses remain sceptical about the value of their input.Patient preparation for discharge including daily living skills,socialization and work skills are important skills for the patients to acquireto help them function in the community. Education about their illnessincluding the importance of compliance with treatment is also necessary toincrease their coping abilities in the community. In addition, communityeducation is necessary to promote appropriate patient care and receptionand tolerance.Resources and facilities in the community were described as lackingin adequacy to provide care for the patients following deinstitutionalization.Access to facilities such as housing, drop-in centres, sheltered workshopsand recreational activities were also necessary to promote the patients well-being in the community.55CHAPTER FIVEDiscussion of FindingsThe purpose of this chapter is to discuss the findings of the study inrelation to the literature. Empirical data were mentioned in chapter 2where a selection of both experientially and research-based publicationswere reviewed. In this chapter the discussion focuses on empirical datawhich either supports or refutes the specific findings of this study.A number of studies were found on the deinstitutionalization of thechronic mentally ill. However, no research was found that focused on headnurses' perceptions of the impact of deinstitutionalization of the chronicmentally ill. Therefore, relevant studies about deinstitutionalization of thechronic mentally ill completed by other disciplines will be used in thediscussion.In the discussion of findings the three content categories which arecontributing factors, impact on the individual and facilitating factors will bepresented. The themes in the contributing factors, hospital mandate todownsize, mental health act and consumer advocacy, will be described.Stigma, homelessness, revolving door syndrome and quality of life will bediscussed in the impact on the individual category. Finally, themes in thecontent category, facilitating factors, communication, patient preparation,education and resources/facilities will be presented.56Contributing FactorsHospital mandate to downsizeSeveral authors (Hayes, 1992; Lamb, 1984; Polcin, 1990; Talbot, 1988)have argued that one of the motivating factors for deinstitutionalization ofthe chronic mentally ill is financial cost. The findings from this studysupport their argument. The head nurses in this study suggested that thegovernment believes it is cost effective to care for the chronic mentally ill inthe community rather than in a large psychiatric institution.However, the head nurses viewed deinstitutionalization as a goodidea if it is "clinically driven" than "financially driven" whereby thepatients would be appropriately selected and adequately prepared with thenecessary coping skills to help them function in the community. Thisfinding is consistent with Minkoff (1987) who claims thatpsychopharmacologic and psychosocial interventions assist the ill person toacknowledge, bear and accept his illness. Also psychosocial interventionshelp the patient to learn new coping behaviours and rehabilitative skills tofacilitate the process of adaptation to the illness. Herman and Smith (1989)state that the deinstitutionalization movement can be effective only if moreemphasis is placed on rehabilitation and reintegration rather than on costeffectiveness.The findings from the study also indicate that some chronic mentallyill patients require "asylum" type care due to the severity of their illnessand length of hospitalization . This finding is congruent with that of Talbot57(1985) and Bachrach (1984) who state that a portion of the chronic mentallyill require care in an asylum.Mental Health ActThe findings from this study also suggest that the Mental Health Act(1979) has contributed to the deinstitutionalization of the chronic mentallyill. Patients admitted on an informal basis could discharge themselves atanytime against medical advice whether they are clinically improved or not.Also an involuntary patient has the right to apply to the review panel fordischarge if he feels he is kept in hospital against his will. According to thehead nurses some doctors are also reluctant to certify patients or to changetheir status to involuntary if the patients were not a danger to themselvesor others. This finding is supported by some authors (French, 1987; Lamb,1984; Roberts, 1989) who report that the different acts governing mentalhealth in the United States of America have resulted in the depopulation ofpsychiatric hospitals. Committing patients to psychiatric hospitals hasbecome a complex process. In addition it is more difficult to hold patients inpsychiatric hospitals against their will.The findings in this study show that "unplanned discharges" impacton the follow-up care and treatment the patients receive in the community.Most times the patients do not receive follow-up care as no plans are madeprior to discharge. On the other hand the patients have the right to refusetreatment. This finding is congruent with Roberts (1989) who stated that58"there are some patients who cannot be subjected to compulsory care underthe present laws governing certification and involuntary treatment. It hasto do with the decision to allow all persons except those imminentlydangerous to accept or reject services offered to them" (p. 297).The findings also suggest that the Mental Health Act has had apositive impact on some patients. That is some patients have more freedomthat enables them to go out and socialize with family and friends in thecommunity as they desire. This finding is supported by Lamb (1984) whosaid "perhaps one of the brightest spots of the effects ofdeinstitutionalization is that the mentally ill have gained a greatlyincreased measure of liberty" (p. 904).Consumer AdvocacyThe findings in this study point to an improvement in consumeradvocacy in the hospital as a contributing factor to deinstitutionalization.Krupa, Singer and Goering (1988) support this finding in their statement"the more involved patients are in identifying their own needs and choosingthe appropriate resource, the more likely they are to be committed todischarge plans" (p. 15). The Canadian Nurses Association (1991) reportsthat consumers and their families want to participate, and that they havethe right to participate, in the decision-making process affecting their care.59Impact on the IndividualStigmaThe study findings show that stigma affects the care of thechronically mentally ill. Several authors (Lamb, 1984; Herman & Smith,1989; Sullivan, 1992; Talbot, 1988) point out that the mental illness is notunderstood by the community therefore the mentally ill are not fullyaccepted in the mainstream of society. Bachrach (1984) also supports thisfinding by stating "the chronic mentally ill are ridiculed, discriminated andstigmatized" (p. 975).Homelessness The findings of the study suggest that homelessness is a result ofdeinstitutionalization for some chronic mentally ill patients. In past yearsmany patients were housed in psychiatric institutions whereas today manyof them live on the streets, "in doorways and in cardboard boxes." Thisfinding is supported by Aviram (1990), Talbot (1985) and Quick (1990) whopoint out that many chronically mentally ill patients are homeless and liveon the streets. This finding is also consistent with media headlines such as"Housing for Mentally Ill Causes concern" (The Vancouver Sun, 1989).In addition the findings from the study indicate that some patientsdid not like living in affordable houses such as boarding homes and familycare homes because their perceived needs were not being met. Reisdorph-Ostrow (1989) reports that "these residences provide few of the necessaryfunctional services and rely on the individual to independently navigate the60community mental health system" (p. 6).French (1987) states that "these residences provide nothing more thana shelter" (p. 503).Revolving Door SyndromeThe findings from this study also point out that the revolving doorsyndrome is an impact of deinstitutionalization on the chronically mentallyill. The head nurses stated that non compliance with medications andfollow-up care in the community contribute to the revolving door syndrome.This finding is congruent with that of other authors (Crawford & Conacher,1988; Holmstrom, 1989; Reisdorph-Ostrow, 1989) who report that non-compliance with medication and treatment result in regression and in therevolving door syndrome.Quality of LifeAlthough the findings of this study identify negative effects ofdeinstitutionalization, positive effects are also found. Quality of life can beimproved for some patients in the community given adequate preparationand support services. "Independence", "privacy" and "dignity" can beachieved in the community as opposed to a large psychiatric institution.This finding is consistent with Okin and colleagues (1993) findings whichstate that some chronically mentally ill patients find community livingbetter than living in an institution. The patients in the study adapted totheir new life style and found their lives improved. This current study'sfindings is also supported by Friedlob et al. (1986), whose study found that61patients with competence in daily living skills, vocational training andmoney management had an improved quality of life in the community.Improvements are in living environment, occupational behaviour and lengthof rehospitalization.Facilitating FactorsCommunicationThe findings in this study indicate that there is a lack ofcommunication between the head nurses and the administrators in thehospital that could facilitate the successful implementation ofdeinstitutionalization. Head nurses can identify suitable patients fordischarge and appropriate placements in the community according topatients needs. Their clinical input can prevent inappropriate patientplacements that lead to inappropriate care and to rehospitalization. Thisfinding is supported by Krupa et al. (1988) who state that "head nursesworking in psychiatric hospital settings are aware of a high rate ofrecidivism among their patients" (p. 14). Parker (1986) points out that headnurses in their professional role recognize the high cost of health care andtry to control expenses.The findings also suggest that communication and "workingtogether" between hospital and the community is important to effectivelydeinstitutionalize the chronically mentally ill and to meet patients' needs inthe community. Polcin (1990) states that "decisions were made almost62exclusively at high levels of government and mental health administrators.The experience of patients, families, communities and professionals wasthat something was being done by an indefinable "they" rather than anopportunity being provided for them to help create new systems that theycould feel invested in and committed to" (p. 185).Patient PreparationThe study's findings indicate patient preparation with coping skills asan essential component for living successfully in the community. Activitiesof daily living, vocational, socialization and money management skills arenecessary for patients to function effectively in the community. This issupported by the findings of Okin et al. (1983) and Friedlob et al. (1986)that showed patient competence in these skills were more functional andadaptive in the community.EducationThe findings also reveal patient and community education aboutmental illness as an important factor in the deinstitutionalization process.This finding is consistent with other authors (Herman & Smith, 1989;Jimenez, 1988; Runyan & Faria, 1992) who state that patient empowermentabout their illness and community education concerning mental illnessmake a difference in the care of the chronic mentally ill. Polcin (1990)claims that "patients are not sufficiently acknowledged and empowered by63mental health systems to adequately understand and respond to treatmentconditions offered" (p. 189).Resources and Facilities The findings suggest that community resources and facilities are vitalcomponents for deinstitutionalization to be successful. Many authors(Bachrach, 1984; Lamb, 1984; Quick, 1990; Runyam & Faria, 1992; Talbot,1988) have argued that community services have not expanded and or areinsufficient to meet the growing demands of the chronically mentally illpopulation living in the community. Wolf and Fry (1990) deem lack of socialsupport in the community is a contributing factor to joblessness and povertyexperienced by the chronically mentally ill.SummaryThe findings from this study, corroborated with empirical data andother relevant professional literature have been presented. The findings ofthe study suggest that deinstitutionalization of the chronically mentally illhave both a negative and positive impact on the well being of thispopulation. The findings identified stigma, homelessness and the revolvingdoor syndrome as negative effects. Improved quality of life was deemed apositive effect of deinstitutionalization. The findings also indicate thatfacilitating factors such as communication, patient preparation, education,adequate resources and facilities can minimize the negative impact ofdeinstitutionalization.64CHAPTER SIXSummary, Conclusions and ImplicationsThe summary and major conclusions of the study are presented inthis chapter. Implications for nursing practice, education, administrationand research are suggested.SummaryThe impact of deinstitutionalization on the chronically mentally illwas elicited from the head nurses. The study explored an in-depthunderstanding of the head nurses perceptions of the impact ofdeinstitutionalization using a phenomenological method. The sampleconsisted of seven head nurses who had a minimum of five years experiencewith the deinstitutionalization process. In-depth semi-structured interviewswere conducted to gather the data. Five trigger questions were used duringthe first interviews to begin exploration of the phenomenon under study.Further questions were asked to facilitate clarification of data duringinterviews. Data were analyzed using Coliazzi's phenomenological methodsas outlined by Reimen (cited in Munhall and Oiler, 1986). Coliazzi's methodstated that the transcripts be transcribed verbatim and read a few times toacquire a feeling for them. Meaning units were formulated from thesignificant statements of the description. Then a cluster of themes wasorganized from the meaning units. Next an exhaustive description of thephenomenon was produced from integration of the results of the analysis.65Major themes derived from the data were organized into three contentcategories which formed the framework for conceptualization of the data.The three content categories were; contributing factors, impact on theindividual and facilitating factors.From the findings of this study, it can be concluded thatdeinstitutionalization is a result of the hospital's mandate to downsize dueto the high cost of caring for patients in large institutions. Also the mentalhealth act has facilitated early patient discharge from hospital to thecommunity whereby informal patients can discharge themselves wheneverthey wish. Discharges through the review panel also contribute to thedeinstitutionalization process. Improved consumer advocacy in the hospitalis another factor affecting deinstitutionalization of the chronic mentally illpatients. However the findings suggest that though the mental health acthas promoted freedom and liberty for the patients, not all patients can copewith community living. Therefore, some patients will require "asylum" typeof care for most of their lives.Deinstitutionalization has some negative effects on the chronicallymentally ill. Stigma has an impact on this population in different ways.Their behaviours are usually misunderstood and misinterpreted to bedangerous to society. Thus, the community shuns them. Homelessnessamongst this population is another negative impact. Due to chronicity, lackof skills and job opportunities most of these patients are unemployed and66therefore cannot pay for housing. Added to that, some patients do not likeliving in affordable facilities such as boarding homes. Many chronicallymentally ill patients experience the revolving door syndrome partly due tonon compliance with medication and treatment. However,deinstitutionalization can result in improved quality of life for somepatients with adequate preparation and support services.The success of deinstitutionalization can be facilitated with improvedcommunication between head nurses and the hospital administrators. Thehead nurses have the knowledge and expertise to know which patients aresuitable for community living, and to suggest appropriate placements thatcan meet patients' needs. Their clinical input can assist in preventingpatient deterioration and rehospitalization. Communication and "workingtogether" between hospital and community can also facilitate the success ofdeinstitutionalization.Patient preparation is another factor that affects thedeinstitutionalization process. Patients with adequate coping behavioursand education about their illness function more effectively in thecommunity. Also community education about mental illness promotesacceptance of the chronically mentally ill in the community. In addition, theadequacy and availability of resources and facilities in the community assistthe chronically mentally ill population cope with the deinstitutionalizationprocess.67For discussion purposes the findings of this study were compared toother research studies and relevant professional literature. The findingsprovide a better understanding of the impact of deinstitutionalization on thechronically mentally ill from the head nurses' perspectives. A number ofconclusions can be drawn based on the findings.ConclusionsThere are four main conclusions to this study.1. Deinstitutionalization does not necessarily enhance the quality of lifefor all chronically mentally ill patients. Some "fall through thecracks."2. Some chronically mentally ill patients require care in psychiatricinstitutions for most of their lives due to the severity of theirillness.3. Deinstitutionalization can be successful for some chronically mentallyill patients with adequate and available resources and facilities tosupport them in the community.4. Head nurses have the knowledge and the expertise to effectivelyassist hospital administrators in the decision-making process in thedeinstitutionalization of the chronically mentally ill. In this hospital,their knowledge is under utilized or not used in this process.From the findings and the conclesions the following implications aresuggested.68Implications for Nursing PracticeDeinstitutionalization of the chronically mentally ill hasimplications for all nurses. Nurses should provide opportunities for patientsto improve their quality of life in the hospital and in the community bypromoting privacy, independence and dignity. Patients should be treated asindividuals with unique needs and desires. Inclusion of the patients in theirtreatment plans would maximise their level of functioning and improvecoping skills.Nurses should advocate for patients' quality care, includingappropriate and adequate services and resources to meet their needs.Nurses in the hospital and in the community must engage in regularcommunication and exchange ideas of treatment and strategies to preventpatients "falling through the cracks." These patients require consistent andfrequent follow-up in the community to assess mental status andcontinuation with reccommendations for care.The nurses may have to go to the patients' places of residence toprovide nursing care as these patients may avoid mental health centres andrefuse nursing care altogether. Also, due to decreased coping skills, thesepatients may be unable to gain access to available resources to help themfunction at their optimal level in the community. Nurses are placed in animportant position to maintain and to promote the well being of thechronically mentally ill patients.69Head nurses have an essential role in influencing the care of thementally ill. They should share their knowledge and skill by lobbying otherhealth care providers within the hospital and in the community to effectchanges in the care of this population.Implications for Nursing EducationIt is clear that a large segment of the population is affected bychronic mental illness. It is also clear that nurses have a significant role inthe provision of care for these patients. The implication is that nurses mustbe educated about chronic mental illness to deliver quality care to thispopulation.This also includes nurses who practice in hospital and in communitysettings who are not caring for psychiatric patients in their regular workareas. However, they may be required to care for a chronically mentally illpatient on a surgical ward or in a doctor's office. Hence they must be able torecognize signs and symptoms of psychiatric disorders to interveneappropriately. Therefore it is important to include mental health theory anda clinical practicum in all nursing curricula from diploma to graduateprogrammes. It is particularly important that students and qualified nurseswork with these patients in hospital and in the community settings tofamiliarize themselves with the problems these patients encounter in bothareas.70Nurses also have a responsibility to educate the community aboutchronic mental illness. This can be done by talking to and by distributingliterature on mental illness to patients' families and friends when they visittheir loved ones. Education may alleviate hostility, reduce stigma andpromote acceptance of this population in the community. Communityacceptance may break down many barriers these patients face therebyimproving their quality of life.Lastly nurses have a major function to play in educating theirpatients about chronic mental illness. Knowledge about their illness, theability to recognize signs and symptoms of regression and the importance ofseeking early help will prevent the "revolving door syndrome" for somepatients.Implications for Nursing AdministrationDeinstitutionalization of the chronically mentally ill has implicationsfor nursing administration. Nursing administrators in hospital are in aposition to make appropriate and well-informed decisions regarding thedeinstitutionalization process by utilizing the head nurses knowledge andexpertise in this area. Administrators must recognize that head nurses whowork with the chronically mentally ill are cognizant of their patients'coping abilities and individual needs required to enable them to function inthe community. To reduce financial cost in the care of this population, it it71important to administrators to consult with and include the head nurses indecisions affecting deinstitutionalization.However, head nurses in their role as leaders, must make their voicesheard to effect change in the care of the chronically mentally ill in hospital.Their participation in committees that influences the deinstitutionalizationprocess is one way to share their knowledge and expertise. Advocatingverbally and in writing on behalf of their patients is another way to haveclinical input in the decision-making process.Implications for Nursing ResearchDuring the research process the investigator became aware of anumber of research questions that evolved from the study findings. Thesample from the current study is head nurses from a psychiatric institution.It would be interesting to repeat the study using the head nurses frompsychiatric units in the general hospital. Such a study will indicate whetherthose head nurses' perceptions are similar to or different from this study'sfindings.One study might address the same phenomenon but from thepatients' perspectives, for example, what are the patients' perceptions of theimpact of deinstitutionalization on their care? Data collected from thepatients themselves would help to identify specific needs necessary forimprovement in their care.72Another study might address the phenomenon ofdeinstitutionalization from the perceptions of the parents of chronicmentally ill patients. A study such as this could potentially guide nurses inhelping them understand the grief, loss and stigma that the familiesexperience. From this understanding nurses could teach parents appropriatecoping behaviours to maintain their wellness.One study could document community mental health nurses'perceptions of the impact of deinstitutionalization on the chronicallymentally ill? Since community mental health nurses are responsible for thefollow-up nursing care of these patients who tend to be non-compliant withmedications and follow-up care, it will be helpful to learn how they copewith these problems.The above recommendations for further research would provide moreinformation for nurses regarding the impact of deinstitutionalization onchronic mentally ill patients. The information will also add to the body ofnursing knowledge that would direct the nursing care of this population. Onthe odher hand, because of this apparently universal trend todeinstitutionalize, soon psychiatric hospitals will house only the very ill orthose needing "asylum", and so such research will not be needed in thefuture.73REFERENCESAviram, U. (1990) Community care of the seriously ill: Continuing problemsand current issues. Community Mental Health Journal, 26(1), 69-88.Bachrach, L. (1984). Asylum and chronically ill psychiatric patients.American Journal of Psychiatry, 141(8), 974-978.Berti, L., Glick, I., & Tansella, M. (1990). Measuring the treatmentenvironment of a psychiatric ward and a community mental healthcentre after the Italian reform. Community Mental Health Journal,26(2), 193-203Brook, 0. (1990). Patients refused admission to psychiatric hospitals in theNetherlands. European Archives of Psychiatry and Neurological Sciences, 239, 325-330.Brown, M. S. (1986). Research in the development ofnursing theory: Theimportance of a theoretical framework in nursing research. In L. H.Nicoll (ed.), Perspectives on Nursing Theory (pp. 11-15). Boston:Little, Brown and Co.Canadian Nurses Association (1991). Mental health care reform: A priorityfor nurses. A discussion paper on mental health care. Canada.Cosbie, R. (1987). Community care of the chronically mentally ill. Journal ofPsychosocial Nursing, 25(1), 33-37.Corke, P. , Cushion, B., & Haddock, G. (1989). Resettlement of long-staypsychiatric patients.Nursing Times, 85(9), 44-46.74Crawford, B., & Conacher, N. (1988). Criminalization of the mentally ill.Canadian Journal of Psychiatric Nursing,(2) 14-16DuBois, C., and Gates, J. (1990). Georgia looks to the future. Hospital andCommunity Psychiatry, 41 (6), 606-607.Friedlob, S., Janis, G., and Deets-Aron, C. (1986). A hospital-connectedhalfway house program for individuals with long-termneuropsychiatric disabilities. The American Journal of Occupational Therapy, 40(4), 271-277.French, L. (1987). Victimization of the mentally ill: An unintendedconsequence of deinstitutionalization. National Association of Social Work. pp. 502-505.Giorgi, A. (1975a). An application of phenomenological method inpsychology. In A. Giorgi, G. Fischer, and E. Murray (Eds.), Dusquesnestudies in phenomenological psychology. Vol. 11 (pp. 83-103).Pittsburgh.Glick, I., Klar, H., and Braff, D. (1984). Guidelines for hospitalization ofchronic psychiatric patients. Hospital and Community Psychiatry,35(9), 934-936.Gralnick, A. (1985). Build a better state hospital: Deinstitutionalization hasfailed. Hospital and Community Psychiatry, 36(7), 738-741.Hayes, E. (1992). Mental health services in British Columbia: A problem ofquality control. Perspectives in Psychiatric Care, 28(1), 24-32.75Health & Welfare, Canada (1988). Mental Health for Canadians. Striking abalance. Ottawa: Author.Herman, N. and Smith, C. (1989). Mental hospital depopulation in Canada:Patient perspectives. Canadian Journal of Psychiatry, 34(5), 386-391.Holmstrom, C. (1989). Community living for the chronic mentally ill.Canadian Journal of Psychiatric Nursing, 30(4), 6-8.Jahoda, A., Cattermole, M., and Markova, I. (1990). Moving out: Anopportunity for friendship and broadening social horizons? Journal ofMental Deficiency Research, 34, 127-139.Jimenez, M. (1988). Chronicity in mental disorders: Evolution of a concept,Social Case Work, 69(10) 627-633.Krupa, T., Singer, B. and Goering, P. (1988). From hospital to community.The Canadian Nurse, 20(1), 14-16.Lamb, R. (1984). Deinstitutionalization and the homeless mentally ill.Hospital and Community Psychiatry, 35(9), 899-907.Lofland, J., and Lofland, L. (1984). Analyzing social settings (2nd ed.).Belmont, CA: Wadsworth.Long, C., Mackle, E., and Monaghan, J. (1989). What happens when thehospital closes? Journal of Psychosocial Nursing, 27(4), 11-14.Ministry of Health, (1987). Mental Health Consultation Report: A DraftPlan to Replace Riverview Hospital. British Columbia: Author.76Minkoff, K. (1987). Beyond deinstitutionalization: A new ideology for thepostinstitutional era. Hospital and Community Psychiatry, 38 (9),945-950.Munhall, P. L., and Oiler, C.J. (1986). Nursing research: A qualitativeperspective. Connecticut: Appleton-Century Crofts.Okin, R. (1985). Expand the community care system: Deinstitutionalizationcan work. Hospital and Community Psychiatry, 36(7), 742-745.Okin, R., Dolnick, J., and Pearsall, D. (1983). Patient's perpectives oncommunity alternatives to hospitalization: A follow-up study.American Journal of Psychiatry, 140(11), 1460-1464.Ornery, A. (1983, January). Phenomenology: A method for nursingresearch. Advances in Nursing Science, pp. 49-63.Parker, G. (1986, June). Pride in being a nurse. RNABC News, pp. 22-23.Pearlmutter, D. (1985). Recent trends and issues in psychiatric-mentalhealth nursing. Hospital and Community Psychiatry, 36(1), 56-61.Polcin, D. (1990). Administrative update: Administrative planning incommunity mental health. Community Mental Health Journal, 26 (2),181-191.Quick, R. (1986). Lost in America. Nursing Times, 86 (30), 44-47.Riesdorph-Ostrow, W. (1989). Deinstitutionalization: A public policyperspective. Journal of Psychological Nursing and Mental HealthServices, 27(6), 4-7.77Roberts, C. (1989). Viewpoint: Development of mental health services andpsychiatry in Canada: Lessons from the past: Problems of the present;and the future. Canadian Journal of Psychiatry, 34(4), 291-298.Runyan, C. & Faria, G. (1992). Community support for the long termmentally ill, Social Work in Health Care, 16(4), 37-53Staff. (1990, January-February). Health in the 1990's. Registered Nurses Association of British Columbia News, pp. 11-13.Sullivan, P. (1992). Reclaiming the community: The strengths perspectiveand deinstitutionalization. National Association of Social Workers,37(3), 204-208.Talbot, J. (1988). Deinstitutionalization: Avoiding the disaster of the past.Hospital and Community Psychiatry, 30(9), 35-42.Talbot, J. (1985). The fate of the public psychiatric system. Hospital andCommunity Psychiatry, 36(1), 46-50.Van Maanen, J. (Ed.). (1983). Qualitative methodology. Beverly Hills, CA:Sage Publications.West Vancouver takes up petition against boarding home for the mentallyill. (1990, May). Vancouver Sun, p. 2.Wolf, S. & Fry, J. (1990). Towards better psychiatric care in the community.Journal of the Royal Society of Medicine, 83(4), 207-208.Woods, N. F., and Catanzaro, M. (1988). Nursing research: Theory andpractice. St. Louis: C. V. Mosby.World a lonely place for the mentally ill. (1990, April) Vancouver Sun.7879APPENDIX ALetter to the AgencyDateThe Vice PresidentNursing ServicesDear,I am a final year graduate student in the Master of Science in nursingprogram at the University of British Columbia. For my research project, Iplan to study the impact of deinstitutionalization of the chronic mentally illfrom head nurses' perspectives. Since your hospital is in an active down-sizing phase and the patients are being deinstitutionalized, I thought thatthe head nurses from your hospital would be able to assist me in myresearch study.I am aware that the head nurses from the acute assessment and treatmentprogram and from the continuing treatment programs are involved in theimplementation of the deinstitutionalization process. I would appreciate it ifyou would givepermission for me to use your hospital and eight head nursesfrom the above stated programs as my sample group for this research study.The purpose of this study is to gain a deeper understanding of the impact ofdeinstitutionalization on the chronic mentally ill as perceived by headnurses. Although there will be no immediate or direct benefits to yourhospital or head nurses, the findings may assist the administrators, policyplanners and other disciplines, enhance the implementation of thedeinstitutionalization process.The head nurses face no risks from participation in this study. I willconduct a minimum of two interviews with each head nurse. To guide theinterviews the same six trigger questions will be used.The data provided will be kept confidential. I will require written consentfrom each head nurse stating their willingness to participate and to havethe interviews tape recorded.Should you need further clarification or information regarding this study,please feel free to phone me at home 941 - 4576 or at work 941 - 3471.Yours SincerelyK. Leila Sinnen8081APPENDIX BConsent FormDateDear ,Thank you for volunteering to participate in my research project entitled"Head Nurses' Perceptions of the Impact of Deinstitutionalization onPersons with Chronic Mental Illness." I would like to inform you that youmay withdraw from the project at any time without penalty. Theinformation you provide will be shared with my thesis committee and willbe kept confidential from others. The tapes will be destroyed uponcompletion of the study.The purpose of the study is to gather an in-depth understanding of theimpact of deinstitutionalization on the chronic mental ill from yourperception. There will be no immediate benefit to you from participating,but the findings from the study may assist in improving patient care,particularly nursing care of the chronic mentally ill. The findings may alsoenhance implementation of the deinstitutionalization process. You face norisks in participating in this project.I will conduct a minimum of two face to face interviews with you and returnto you for data clarification as necessary. I will use five trigger questions toguide the interview. The interviews will take place in a convenient locationfor both of us, preferably away from your work area. Please call me forfurther information at 941-4576 or (Bus) 941-3471.I consent to participate voluntarily in the project.Signature of participant^Date^I consent to have the interviews tape recorded.Signature of participant^Date^Yours SincerelyK. Leila Sinnen82APPENDIX CTrigger Questions1. Describe your involvement with the deinstitutionalization process?2. From your perception how does deinstitutionalization affect yourpatients?3. What are the benefits of deinstitutionalization for your patients?4. From your perception what are the shortcomings of deinstitu-tionalization for your patients?5.^How can you influence the deinstitutionalization process in thishospital?83

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