The deinstitutionalization of patients with long-term mental health problems has met with some success as well as with some failure. Although the concept of deinstitutionalization in theory is attractive, the implementation has been problematical for many communities. In order to minimize these failures, a college of nursing (The University of Iowa) and a mental health center (Linn County Psychiatric Clinic) entered into a joint project to improve the quality of life of deinstitutionalized patients and decrease the patient readmission rate. We have found this program successful and would like to recommend it to others as a worthwhile and rewarding adventure.
History of Deinetitionalization
After the advent of thorazine and other drugs in the 1950s and 1960s, it became possible for people with long-term mental health problems to live outside the confines of an institution. Professionals noted that the effects of long-term hospitalization promoted much of the observed symptomatology (Stanton and Schwartz, 1954). Mental health professionals came to realize that the large mental hospital isolated the patient from the community and his relatives, undermined motivation to return to the community, and induced a disability that was above and beyond the consequences of his mental condition (Mechanic, 1969).
In 1963, the Community Mental Health Act was enacted which implemented the recommendations of the final 1961 report of the Joint Commission on Mental Illness and Health entitled Action for Mental Health. These recommendations included decreasing the size of psychiatric hospitals and establishing programs of care for the chronically ill in the community. However, it wasn't until 1975 that amendments to the Community Mental Health Act were passed in which mental health centers were mandated to provide specific services such as follow-up care and transitional facilities to discharged patienta.
The concept of deinstitutionalization can be denned as the right of any individual to receive treatment in an environment which is the least restrictive. The Mental Health Law project of 1973 defines the least restrictive environment as:
... a person should not be hospitalized, with drastic curtailment of liberty involved, if he can be treated in a setting less restrictive than an institution as required by the constitutional principle of the least drastic means. The Constitution requires that whenever a government is going to restrict a person's liberty against his will in order to accomplish a legitimate governmental objective, it must impose the least drastic restriction necessary ÍScheerenberger, 1976, p. 126).
Although there are legislative mandates for the care of the chronically ill in the community, in actuality many programs have not met that goal and are in fact deficient. There are many reasons for the failure of deinstitutionalization programs in the community. Nurses at the mental health center in Cedar Rapids, Iowa, found failure to maintain medication compliance, lack of reference and support groups, and inability to function independently in the community as the most important factors in the readmission of their patients to the state hospital. Many patients would forget to take medication, and the consequent low, non-therapeutic blood levels of the medication would necessitate readmission. Many patients did not understand the biochemical and physiological reasons for medication, saw medication merely as a tranquilizer, and would stop taking the drug.
Patients who were subjected to long-term hospitalization often identified their reference and support groups as the patients and employees of the hospital where they had spent many months or years. Many of these patients' families had disengaged and no longer included the patient as part of the family. The mental health center felt it was a necessity to develop a support system locally so that patients would prefer to remain in the community with their friends rather than be rehospitalized. It was found that long-term institutionalization had created such a great dependency that many patients could not function independently in the community. Some were unable to utilize services such as the bus system and financial aid without help. In response to these problems the Linn County Psychiatric Clinic in Cedar Rapids, Iowa, and the College of Nursing at The University of Iowa in Iowa City, Iowa, entered into a cooperative agreement to help provide services to decrease hospitalization and to provide students with opportunities to work with long-term patients in the community.
Overview of Project Development
In 1974, the College of Nursing implemented a new curriculum which integrated concepts of health and community care in all five nursing core courses. Students are exposed first to healthy adults in a home setting and progress to the care of sick adults, children and families in the hospital and community. Nursing interventions are taught and practiced which promote, maintain, and restore health in a variety of settings.
Nursing IV, a senior level core course, focuses on care of the chronically ill person. Students are provided with clinical experiences in the hospital as well as the community. Each student has a caseload of two to four chronically Ul patients and their families who are visited weekly during the semester. Nursing IV faculty have developed contracts with several community agencies for these learning experiences such as Visiting Nurse Associations, Public Health Nursing Agencies, County Care Facilities (formerly County Homes), and a Psychiatric Clinic (Mental Health Center).
In 1975, the College of Nursing worked with the staff of the Psychiatric Clinic to arrange for students to visit patients weekly in their homes, at sheltered work settings, or at job sites. The first student visits culminated months and hours of negotiation, organization, and planning between the Clinic and the College of Nursing. Approval was received from the Board of Directors of the clinic and the administration.
Nurses in the clinic initially discussed the atudent nurse program with clinic patients who were assessed to be capable of benefiting from this service. Appropriate releases of information forms were signed and students were provided information about the patient's background, treatments, and goals for care. The instructors helped select patients who would be suitable candidates for teaching experiences and a caseload was selected.
The faculty and clinic staff developed policies about home visits by students in Nursing IV. General guidelines for student visits, charting, and channels of communication were developed by the Clinic and the College of Nursing. Orientation to the Clinic was an important aspect of this project, and policies and procedures were developed to guide faculty and students. The nurse in the Clinic came to the College of Nursing building for this orientation when students were assigned cases. This was very effective in maintaining open communication with faculty and staff, and students were able to observe the collaborative process in action. Many commented on the excellent role model this nurse provided, and consequently began to think about a career in psychiatric nursing. The nurse from the Clinic oriented the students to the Clinic, to the community services available for long-term patients, and to the concept of deinstitutionalization and goals of treatment for patients with chronic mental health problems. Students were invited to speak with the patient's individual therapist, and were encouraged to attend various programs their patients might participate in at the Clinic such as day treatment and coffee groups.
As the student traveled to the patients' homes the instructor was available at the Nursing Building and the Clinic nurse was available at the Clinic. The College of Nursing and the Clinic are approximately 25 miles apart. Elaborate telephone coverage was planned so no student would be unable to reach either an instructor or therapist in a time of crisis. At the end of the day students returned to the College of Nursing where the patients' records were maintained. Verbal reports were also given to instructors who then contacted Clinic personnel by phone if problems had occurred during visits that would require intervention before the next weekly visit. Routine weekly updates on the patients were written by the student and mailed to the Clinic at the end of the week.
Patients were sometimes not at home. New assignments were then made for the students. When treatment protocols changed the instructor was notified and this was discussed with the student before the next visit. Every student met with the instructor before and after each home visit. These pre- and post-conferences have been very instructive for the student's understanding about the patient's illness and available community resources. Students were expected to prepare a nursing care plan before the pre-conference. At the postconference this was evaluated and the plan modified for the next visit.
The student nurse program has become very popular among patients. The number of patient requests for a student nurse always exceeds the supply. Sometimes patients are wilhng to share their student or have a student for only one semester.
College of Nursing and Clinic personnel have evaluated the program each semester as charts are returned to the Clinic and plans made for the next semester. Because course enrollment fluctuates between fall and spring semesters, careful planning has been done to maintain patients by the Clinic staff when student numbers decrease and their caseload drops. Usually one to two instructors with 16 to 24 students are assigned to the agency for weekly visits to two or three patients by each student. A summary report, "Interim Reports of Home Visits," is prepared by the student for each patient when the semester is completed and charts returned to the Clinic.
There are several times during the year when students are not available to patients such as between semesters and over the summer when student numbers are reduced- During these times therapists in the Clinic schedule extra visits with the patients, encourage more frequent attendance at coffee groups, and utilize public health nurses. Unfortunately, due to personnel shortages, the intensive level of care inherent in the student nurse program sometimes cannot be maintained during semester break and over the summer.
The goals of the students center around the overall goals of the treatment plan developed by the Clinic, but also include individual goals that the patient and nursing student contract for together.
Education about medication is almost always included as a goal for all the patients. The students have developed excellent teaching plans to help the patients understand the necessity of medication. The students are highly trained to observe changes in the symptom pattern of the patients, and to help patients report symptoms to their therapist at the first occurrence. The students have developed some innovative ideas for helping the patients to remember to take medications, and learn to assess the effectiveness of the prescribed medication. If medication compliance is a problem, the students are able to make an assessment of this very early and plan various interventions.
One of the most significant things the students have been able to do is to develop a community support system for patients living in the community. The nursing student visiting is in itself a support system for the patient. Some students and their assigned patients meet with other pairs of students and patients so that a network of patient relationships can be established for support. The students in some situations have helped educate relatives or significant others about particular aspects of the psychiatric illness and ways of relating more effectively with the patient.
Many patients with whom the students worked have been unable to utilize community services. The students have made assessments of these skills and helped the patient to develop the vital behaviors that are lacking. For example, students have taught patients to ride the bus, have accompanied patients to the Social Security Office to help them work through problems about Social Security disability, and have assisted in obtaining food stamps and other types of financial assistance. The lack of suitable housing for discharged patients has been a very difficult problem. However, studente have been able to help patients find new housing, secure financial assistance for housing, and have helped patients to confront problems with landlords and neighbors.
The quality of Ufe of discharged mental patients has been described as one of alienation and loneliness in which the patient is often detached and outside the mainstream of the community. The students have helped to alleviate this problem by helping patients develop support groups and utilize their leisure time more effectively. Patients are encouraged to participate in activities with other ex-patients that they learned at the hospital such as bowling, playing cards, and other recreational activities available in the community. The Clinic personnel have been able to secure discount rates at many recreational centers which helps to ease the financial burden.
Nursing IV faculty have been enthusiastic about this joint project because students have been able to operationalize chronic care concepts in the community setting. Students have been encouraged to work independently, consult with the instructor and Clinic nurse, and be accountable for their own actions. To many students, driving a car by themselves to the first home visit accomplished this objective!
By caring for a group of people over a long period of a semester, students begin to appreciate attainment of small goals, subtle change, and frustration at no change. This is the first time in the curriculum that students have worked with the same patients for an entire semester. They can actually experience many concepts of chronicity themselves.
By scheduling pre-conferences for a small group of students, learning is enhanced by the sharing of planned interventions and patient responses. Peer evaluation often begins here, and students feel support from colleague approval, questionbig, and evaluation. The instructor is able to evaluate nursing care planning, communication skills, dependability, responsibility, and use of research studies in planning interventions.
College of Nursing faculty are able to maintain patient caseload with the Clinic nurse. This has led to improved nursing care, better teaching, and research studies. Students learn about chronic disease and the role of the community in maintaining wellness outside of an institution. Often their interest is sparked m a later career in community nursing.
The College of Nursing and the Psychiatric Clinic are pleased with the arrangements described in this article for promoting healthy adaptation to the community for patients discharged from a psychiatric institution. Both students and patients have benefited. As our program continues we suggest other faculty and practitioners consider such a plan for patients returning to life in the community.
The authors gratefully acknowledge the help of Sue Rebak, RN, of the Linn County Psychiatric Clinic, in implementing and sustaining this project.
- Mechanic, D. (1969). Mental health and social policy. Englewood Cliff's, NJ: Prentice-Hail.
- Scheerenberger, R.C. (1976). Deinstitutionalization and institutional reform. Springfield, JL: Charles C. Thomas Publishers.
- Stanton, A.H., & Schwarte, M.S. (1954). The mental hospital. New York: Basic Books.