Patient-initiated brief admission for emotional instability and self-harm

Abstract

Background: Previous studies have reported negative experiences of psychiatric inpatient care for patients with emotional instability and self-harm. A novel intervention called patient-initiated brief admission (PIBA) has been developed, as a constructive crisis management for patients in situations of increased anxiety and thoughts of self-harm and suicide. The intervention allows the patient to directly call the psychiatric ward, to initiate a short admission (1 Ð 3 days). This easily accessible form of care may prevent the escalation of anxiety and self-harm during a period of crisis and also reduce need for prolonged admissions.

Aims: The overall aim of the present thesis was to increase the understanding of PIBA as a crisis intervention for patients with emotional instability and self-harm. The specific aims were the following: (1) to describe psychiatric nursesÕ experiences working with PIBA, (2) to explore patients´ experiences of PIBA and what they consider to be the key components and areas which can be improved, (3) to explore how PIBA impacts the psychiatric symptoms and health-related quality of life after the intervention, and whether the patients perceive PIBA as a constructive crisis intervention, and (4) to explore the effects of PIBA on psychiatric care consumption.

Methods: To achieve an increased understanding of PIBA from different perspectives, a mixed set of study designs and methods were chosen. Study I and II had a qualitative design and study III and IV had a quantitative design.

* Study I: Eight nurses were interviewed using semi-structured interview guide and data analyzed according to qualitative content analysis.

* Study II: Fifteen patients were interviewed with a semi-structured interview guide and data analyzed according to thematic analysis.

* Study III: Hundred and thirteen patients experiences of PIBA was evaluated in a pre-post test naturalistic study design. Data was analyzed with paired sample T-tests. Effect sizes were evaluated by Cohen´s d .

* Study IV: A register-based study including data from both inpatient and outpatient care registers, collected from The National Board of Health and Welfare in Sweden. The PIBA group comprised 113 patients and the control group 5769 patients, all diagnosed with BPD during period January 1, 2016, to December 31, 2019. Multi-level models for count data were used in the data analysis.

Results: The main findings for each study were as follows:

* Study I: Nurses´s experiences with PIBA: `provides security and continuity, `fosters caring relationships`, `shifts focus towards patient´s health` and `empowers the patient`. The nurse`s role shifted from `handling problems` to establishing caring relationships with a focus on the person`s health and possibilities for recovering instead of management of psychiatric symptoms.

* Study II: Patients´overall experiences of PIBA: `a timeout when life is tough`, `it is comforting to know that help exists`, `encouraged to take personal responsibility`, and `it is helpful to see the problems from a different perspective`. Key components of PIBA: `a clear treatment plan`, `a smooth admission procedure`, `a friendly and welcoming approach from the staff`, and daily conversations`. Areas for improvements: `feeling guilty about seeking PIBA`, `room occupancy issues`, and `differences in staffÕs competence`.

* Study III: A significant decrease in symptoms of anxiety and depression was found. Health-related quality of life increased significantly and 95.2% of the participants found PIBA to be a constructive intervention.

* Study IV: The control group reduced the number of days in psychiatric inpatient care yearly by 16% during follow-up (up to five years), while a further reduction by 14% was found in the PIBA group (p = 0.064). There was no significant difference between the two groups regarding total number of visits in outpatient care during the study period.

Conclusion: The findings from study I-III indicate that PIBA constructively supports patients with emotional instability and self-harm during a period of crisis. Study IV show promising results in reducing psychiatric inpatient days with potential to reduce health care costs.