STRATEGIES OF IMPROVING REHABITATION SERVICES: MOVING FROM HOSPITAL TO COMMUNITY

MEIDIANA DWIDIYANTI SKp, MSc

Abtrak

Rumah Sakit Jiwa Semarang tahunan tergambar bahwa 56 % dari pasien yang masuk rumah sakit adalah mempunyai usia antara 24-44 tahun yang kita ketehui termasuk usia produktif. Dari mereka menurut laporan, rata-rata pulang pergi ke rumah sakit satu sampai sepuluh kali.Menurut mentri kesehatan ada 25% orang indonesi sakit jiwa(2008). Saat ini banyak keluaraga yang mempunyai orang sakit jiwa cenderung mengandalkan  penyembuhannya dari sakit jiwa hanya dengan obat-obatan. Sedangkan banyak masalah yang berkaitan dengan adaptasi psikologi tidak dipahami oleh mereka. Semantara itu orang sakit jiwa yang baru pulang dari Rumah Sakit perlu di bantu oleh keluargaya dan masyarakat untuk beradaptasi dan ini sangat membantu proses penyembuhan  pasien.Tulisan ini menggambarkan tentang masalah-masalah yang muncul akibat masuknya pasien di rumah sakit dan pentingnya kerja sama rumah sakit dan masyarakat untuk pelayanan kesehatan yang berkelanjutan

A.INTRODUCTION:

Many people with a major mental illness experience poor self-concept and have reduced opportunities to experience meaning in their lives.  Bachrach, (1986) states that patients with a mental illness experience a wide range of problems which impacts on their ability to live successfully in the community. They include diminished social networks, stigma, poverty, unemployment and a general lack of belonging. This is clearly highlighted in my hometown in Semarang Indonesia, where individuals, who have mental illness, always return to hospital after being discharged. How they live in community with depend on their family, unemployment. From the author’s experienced, there are various factors which influence these situations including social withdrawal, estrangement from friends because of stigma of being mentally ill and over-protection of the parents.

Hume, (1994, p.1) state that “rehabilitation is the process through which a person is helped to adjust to the limitations of his disability. Where lost skills may be regained, or new coping strategies developed, so that the person achieves competence. The nature of the impairment dictates the particular focus of rehabilitation, but at all times the person must be treated as an individual”.  When one thinks of disability arising from mental ill in these terms the enormous size of the problem of rehabilitation becomes apparent.

Mental health services have been reformed in Australia and this has been ongoing since 1992. Models of care have been changed from institutional care to community based care. Staffs are working in new ways (Queensland Health, 1994). The new community-oriented approach to the provision of mental health services has raised the challenge of responding to all individuals’ life needs in community settings (Commonwealth of Australia, 1995).  In Semarang, there are no community services for people who are mental ill, which can provide social support, are likely to beneficial. According to Mueller (1980) the enhancement of the benefits of social support to people with a mental illness is important because people with enduring mental health problems are known to have restricted social networks.  One family said that when doctor stated that my son was planned to go home, I am felt sad because I can not do everything and he made self-conscious in daily of life and I have embarrassed with my neighbour.

Leff et al (1982) states that In the mid 1950 medication such as Largactil created an important break- through in treatment of schizophrenia. Side effects from psychotropics may occur in up to 100% of patients treated and lead to drug discontinuation in about 5%-10%. Side effects, they may also cause irreversible neurological damage, and even death (Dewan, 1989) Published research has demonstrated that education and support from carers, with appropriate medication, reduces the relapse rate for sufferers. This statement link with the situation in Semarang. A family stated that their son was not co-operating to take his medicine. They never thought that besides medicine, there are important things, which can help their son to recover. These are family and social supports in the community. There is a stigma that people mental illness can not work. Therefore, people in the community always isolate them. Families who have a member with mental illness send them to hospital. The management of the patient’s problems will then depend on the provision in hospital. The rehabilitation process requires the involvement of a number of people. Family and friends, fellow patients and hospital staff, all play their roles (Lakey and Simpkins, 1994:xv).

Clearly they need a rehabilitation program, but families avoided seeking to solve the problems. This is because, they do not know, after going home, how families can help the people with mental illness. And the community have stigma that mental illness are a curse and make trouble in the community.

In the psychiatric hospital, in Semarang, the annual hospital report (1998/1999) statistics highlighted that more than half of the number of patients (56%) was between 25-44 years old. These people, because they were young, can be independent and productive individuals in their lives. However, despite their potential some of them have frequently returned from one to ten times to hospital. It appears there are problems with institutionalisation. , Jennings (1983) suggests that for every 100 000 of the population aged between 15 and 64, between 24 and 36 adults in 1979, there were likely to be newly recruited long-stay patients. Many patients thus remain dependent on hospital services and can never be rehabilitated to independent living. Evidence suggests that even when long-stay patients are discharged, few achieve full independence from hospital services (Norman and Parker, 1990). Some patients after leaving hospital choose to follow a day care program, this means that, they can work in the hospital such as, in the kitchen, in the hospital office and workshop. Some parents give salary to their children not the hospital. The hospital report (1998/1999) stated that there were 57 women and 57 men following this program. All rehabilitation programs focus on the hospital. From these situations, problems are perpetuated in the community; stigma is reinforced on family.  These support the incorrect belief that people with mental illness are considered to be sub-human. The author has observed that some families with a member with mental illness always close the door and window. Furthermore, they have difficulty in making relationship with their neighbours.

The hospital has a program that is home visit. Social workers and staff from hospital visit the patient’s families. The reasons are, because, families never visit patients in hospital and some families, never contact the hospital (the report psychiatric hospital, 1998/1999). In community there are no education and information to help families understand problems with mental illness. So with information and education lead to behavioural change and bridges the gap between hospital and community.   Hamilton et al (1989) argue that family intervention programmes aimed at educating relatives and helping them cope more effectively with the patients illness have shown positive effects on the course of schizophrenia. Based on these statements, the author intends to set up a strategy for improving rehabilitation services moving from hospital to community with education and information of people with mental illness to the families and neighbours in community, Semarang, Indonesia.

B.LITERATURE REVIEW

Individuals with psychiatric disabilities have the same goals and dreams as anyone else. These include a decent place to live, an appropriate work environment, social activities and friends (Palmer-Erbs & Anthony, 1995). The mission of psychiatric rehabilitation is “to help individuals with psychiatric disabilities to increase their functioning so that they are successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention” (Anthony et al., 1990, p.151). Anthony et al., 1990 state that the goal of rehabilitation programs are focusing on:

* Functioning (Performance of everyday activities)

* Success, (meeting requirements of other people in the client’s world)

* Satisfaction ( the client’s feeling of happiness)

* environmental specificity (the specific context where the person lives, learns, socialises or works),

* Choice (self-determined goals),

* Outcome orientation (evaluation based on client outcomes), support (assistance provided for as long as needed and wanted) and

* Growth potential (improvement in functioning and status).

Evidence from studies (Gibbon et al 1984) show that the vast majority of families living with someone with a long -standing psychiatric complaint experience considerable emotional and physical hardship. Families often need guidance on how to react and behave as they may be dealing with behaviour and emotions that are new and frightening.

The involvement of patients in the planning of their own care has been a key theme of Government policy in community and continuing health care throughout the 1990s (DOH, 1995). Evidence also suggests that ” patients are often not sufficiently involved in decisions about rehabilitation” (Audit Commission, 1996). Clearly, it is important that a comprehensive range of rehabilitation services should be available. But it is also important that clinical and care staff increase the involvement of patients and carers in the assessment of needs and the formulation and implementation of treatment plans.

C.PROBLEMS INSTUTIONALISATION

The institutionalisation problems are two kinds:

1. Institutional syndrome. According to Barton (1959) and Goffman (1961) in Pullen (1994), state that “the institutional syndrome, which is characterised by: apathy, lack of initiative, lost of interest, submissiveness, lack of expression of feeling, loss of individuality and deterioration in personal habits. In the psychiatric hospital, there are many regulations, which make patients life not like themselves. Patients should get up in the morning, take breakfast, and take shower. Nurses should monitor their activities in every day life. Although nurses always try to look after patients as human being. However, there is evidence in relation of institutalisation that according to Alaszewski (1986)  ” there were several ways in which this relationship was maintained, through the patients classification system, the daily routine of basic care and, when all else failed, through physical control”.  From this statement, provide evidence that patients in psychiatric hospital have difficulty to develop into independent.

2. Mere admission to a psychiatric unit stigmatises the patients. Pullen (1994) states that “the attitudes and expectations of the patients, as well as those of people about him, change as a result of being in hospital. This affects the chances of successful adjustment back into the community”.  In Psychiatric hospital, as providers have attitude and stigma as well as people in the community, these have direct effects on the recovering of patients in hospital. Provider in health care practice should have an expectation to help people with mental illness to become normal people.  The hope can influence a motivation to people with mental illness to become normal people in the community.

An emerging problem is the small number of adult psychiatric patients who remain in need of care for long periods in spite of active treatment and rehabilitation. Nikkonen, (1995) states that “as the number of mental health beds has been reduced, there has not been a reduction in the incidence of psychiatric illness in the general population”. Its, because the families and the community are not prepared to accept people with mental illness. King (1997) states that ” it was also unrealistically expected that families would now care for relatives who had been institutionalised for long periods of their lives”. It appears that is not easy to move from hospital to the community. Furthermore, the collaboration between hospital and community become important part in rehabilitation services.

D.STAGES OF REHABILITATION INTO HOSPITAL AND COMMUNITY

In hospital

Rehabilitation services should start from hospital. The first stage is, preparing for moving in another unit or in the community. For someone newly admitted to hospital, rehabilitation begins with diagnosis, it means, as treatment of the acute illness is initiated, general plans for future management should be discussed (Hume, 1994). The second stage is bridging the gap. Rehabilitation, does not end with discharge, the patients should face with the realities and problems of life in the community. They need to help adaptation with the situation. Support from people, who was known and trusted people, would help them during this bridging phase (Hume, 1994). The last stage is community support, “continuing support will be necessary to maintain progress, provide help at times of crisis and prevent deterioration” (Hume, 1994). One possible solution to the chronic patients’ problem suggested by the 1975 white paper (DHSS 1975) is hospital hostels. These are intended to provide continuing treatment and 24-hour nursing care, but with more emphasis on rehabilitation and a high quality of care in a more domestic and less institutional setting than hospitals (Norman and Parker, 1990). There is a growing consensus that mental health service should help people with serious mental illness maximise their opportunities to live independent and meaningful lives (Stein, 1999).

Based on the statements above, rehabilitation services should be begun from the admission to discharge planning.  In order to move rehabilitation services from hospital to community discharge planning is essential.

E. DISCHARGE PLANNING.

After patients discharge from hospital, they have rights to continue their life as normal people in the community. Patients leave from hospital, need to be prepared through discharge planning, which should be made by nurses/team in the hospital (Bean & Mounser, 1993).

Discharge planning is conducted by belief that a horizontal transition from hospital to home is as necessary to the patient (Rorden & Taft, 1990).  Ryan (1994) states that key elements of discharge planning are:

* Patents/carer involvement in the decision making process.

* Adequate notice of discharge to patients and carers

* Bridging the communication gap between hospital and community

* Education of patient and carer.

It appears that nurses need to prepare patients and families in term of transferring them back to the community.

F. DISCHARGE PLANING AS A PROCESS.

Rorden & Taft (1990, p 22) state that discharge planning as “a process made up of several step or phases whose immediate goal is to anticipate changes in patient care needs and whose long-term goal is to insure continuity of health care”. May be they need for medical attention to the first time, may well dominant all other concerns and need. However, awareness of patients’ personal strengths and partial psychosocial needs are pushed to the part in the aspect of medical emergency. The diagram shows that in this phase there are factors such as financial resources, family support and social system could influence the patients’ problems, which should be recognised. In this phase, patient’s; background experiences and belief about health continue to influence their decision-making.

Transitional phase

Entering in the transitional phase, new needs emerge. Although the need for acute care is still present. To begin to plan positively for continuing care is both supportive and frustrating. An examination of patients’ personal strengths, available resources, and the quality of family and social support system will logically move up concerns about whether their needs will be met in another setting. They permit patients the autonomy to plan truthfully and rationally for their continuing care.

The continuing care phase.

Now the plans that had been made in anticipation of needs begin to be implemented. If the patient’s discharge was to home and community cares. Patients need family and social support, to help in adaptation with their life.

From the process of discharge planning shows that the scope and complexities discharge planning need to be understand, to help nurses to make discharge planning to prepare patients back to the community.

G. IN COMMUNITY

According to Taylor and Gunn (1999) in the 1990s the question about whether a person with mental problem should be in hospital or in the wider community seems to have shifted only to become more of class dilemma. People attitude in the community sometimes make life can be very frustrating for people with mental illness. The community is a more open and chaotic environment than institution. Robert (1998) states that while many clients undoubtedly benefit from care in the community as opposed to care within an institution because of the freedom it affords them, it is nevertheless the case that who are feeling fragile often feeling unsafe in the community. Consequently, to make rehabilitation services move from hospital to community. There are some activities to prepare people in the community setting should be planned, these are:

1. Family should be prepared (Elliot, 1994).

It has been recognised for long time that certain types of interaction between patients and their families can impede the rehabilitation process and result in re-anmission (Vaughn & Leff 1976). People with mental illness need support mainly from their family. But some families have anxieties because they do not know what the roles of the family to help them. Elliot (1994) states that families are also encouraged to develop their problem solving skills to avoid stressful situations.

It appears that families should are given information and education to deal with them.

2. The importance of media images (Philo, 1996)

It is recognised that the media have a positive part to play in encouraging attitudes which are conducive to good health (DOH, 1992).   Birch (1991) has written of how stigmatising media images can inform a circle of negative responses, both in user and services and in those who care for them. Media coverage of schizophrenia such coverage interacts sufferers, their professional attendants, and their families, in a restricted set of responses to the illness. From these statements show that the content of media images and illustrate have an impact on public

beliefs, on the feelings and experiences of mental health service users and on the attitudes and responses of carers. It appears, the roles of media have influenced the community, where people have wrong belief about people with mental illness. As results people with mental illness have difficulty to become normal people in the community. But community can also use the media products, to make public can more aware of mental illness people as human condition. They can recover and they can resume normally functioning (King, 1995 in Philo, 1996)

3. Increasing people awareness through information and education (Jenny, 1978).

Jenny (1978) lists three principles of patients/community learning that she believes underlie any health education programs, These are as follows:

His perception of himself, the world and how he relates to the world govern a person’s behaviour. An initial task of the nurses is therefore to ensure that the client has a realistic perception of his situation.

People tend to behave in a way that enables them to avoid feelings of personal in adequacy. The primary challenge for the nurses is therefore to help the client feel that he can cope with learning tasks that lie head.

Needs perceived as immediate receive a person’s attention first. Concerns uppermost in the client’s mind must therefore be dealt with before he will direct his attention to more distant eventualities. However, the need a tools for providing information.

It appears people with mental illness need support from the community. In Indonesia need social network to help them. However, community is needed to make a social network. Families who have members with mental ill people did not need too much medicine, and spent too much money to help patients. But they need support from the community. Furthermore community need to understand of people with mental illness through information and education.

The purposes: Manager and nursing staff know the institutionalisation problems in psychiatric hospital. And they make a program to move the rehabilitation services from hospital to community.

The objectives:

Community understands and receipts psychiatric difficulties people from hospital.

Rehabilitation program uses the resources from the community, including human resources.

1. They establish team to make social network and this team will use resources in the community.

2. The team make an information and education programs in the community.

How to improve rehabilitation services from hospital to community in Semarang?

Strategic plan

In psychiatric hospital Semarang, there are committees to improving quality of care. These committees are:

1. Nursing accreditation team

2. standard monitoring team

3. Training and development team.

Directors of hospital, establish a quality improvement control team to monitor quality of health care practice. In 1999, they have rehabilitation programs are: Home visit, art show, travelling, day care, group therapy and family gathering (hospital report, 1998/1999). The government gave fund for this program.

Plan of action

1. Set up a team, there are people from the psychiatric hospital and the community.

Key person in community, there are teacher, religion leaders and district leader from government and the resources, there are community health centre, Academy of nursing, and company. They should meeting to discuss that people with mental illness need their help. They should make an agreement to make a team; this team is unity between the psychiatric hospital and the community. Mission statement strategy, is mental ill people need to support in the community, we help them to become human being as ourselves.

2. Operational framework to identify a community person to lead the social network. Aims and objectives of the social network will be identified within the context of offering support, information and pre discharge planning for patient and family carers.

Framework to implement the rehabilitation services moving from hospital to the community.







Organisation structure:

                                                 Hospital manager and key persons

                                                                Team works.



                                         Nurses social worker doctor family worker.



Community

* Hospital manager and key person have responsibility for this project. They should choose some body as manager of the project.

* Teamwork consists of people from hospital and from community, to work together; this team consists of nurses from community health centre, social worker, general doctor, families and workers. They should have responsibility for giving of education and information in the community.

* Community is given education and information from the working team.

3. Set up educational resources to help family carers and patients make the transition from hospital to community services. The government gives funding to the hospital to make rehabilitation programs

* A small pamphlet designed for general distribution to heighten public awareness and reduce stigma. It contains some basic facts and sources of help.

* Literature for a Relatives’ supports group, comprising a format for seven consecutive weekly meetings. This literature includes the following: group aims, a welcome letter, and a programme for attainder.

Hospital managers invite key persons from communityDirector, leaderHospitalTo collaborate between hospital and the community to make social networkThere is MOU(memory of understanding) between hospital and community to make social networkThey make programsLeader from the social network teamCommunityTo make strategic planning to improving rehabilitation services that based on a communityThere is job description between hospital and the team from community.Discuss the role’s nurses to implement his program.Leader from the team quality of care in hospital.HospitalTo make discharge planning to prepare patients move in community.There is discharge planning that is made nurses and familyThey make a social network in communityLeader from a communitycommunityTo prepare community, they should release that ‘ex- psychiatric patients’ need to help from a social network.Hospital make education and information training for  families, friends and key person from the communityKey person from the community give a education and information to the communityLeader, and social networkCommunityTo prepare the community receipt patients from the hospitalThe people in community receipt booklet, pamphlet and video recording from team. They discuss the mental illness problems in communityMeeting to evaluate regularlyLeader, and social networkCommunityTo improve rehabilitation services anytimePeople in community, aware and support mental illness from hospital, which could live as human being.

Evaluation;

How to evaluate, this project? This project should be evaluated, whether success or not. The criteria to evaluate this project are:

1. The psychiatric hospital staffs understand the rehabilitation problems in their work, these problems are institunalisatation. They could explain how the impact of this problem to the patients and their families.

2. The psychiatric hospital will give funding to the project.

3. There are booklet, an audio recording and small pamphlet to spread in community to give information and education in the community.

4. The hospital and key persons in the community meeting regularly to evaluate this project.

5. Nurses in the psychiatric hospital make discharge planning to prepare patients to the community. There are forms to assess the patient’s problems to prepare patients to the community. This form includes assessment form to the family, patients and the resources in the community, which could help and support patients in the community.

6. People in the community :

* Always paid attention to people with mental illness and they have willing to discuss stigmatise and their wrong belief.

* Families who have member with mental illness, easy to make relationship with their neighbour.

* Families always proactive to help people with mental illness in their home.

7.  People with mental health save and could live as human being. They have opportunity to get job and develop their capability as normal people. And the psychiatric hospital should give payment to mental illness people who have worked in the hospital (not the family who have member with mental illness

.

REFERENCES:

Alaszewski, A (1986) institutional care and the mentally handicapped. Croom helm, London.

Audit Commission (1996) United They Stand: Co-ordinating Care for Elderly patients with hip fracture. Audit Commission, London

Anthony, W., Cohen, M., & Farkas, M. (1990) Psychiatric rehabilitation. Centre for psychiatric rehabilitation: Boston University, Boston.

Byrne, P (1999). Stigma of mental illness, changing behaviour. British journal nursing, 174,1-2

Birch,J. (1991) Toward the restoration of traditional value in the psychiatric schizophrenia, Contex, 8:21-26.

Bachrach L  (1986) Dimention of disability in the chronicle mental ill. Hospital community Psychiatric 37: 981-2.

Bean P & Mounser P (1993) Issues in Mental Health, Discharged From Mental Hospital. Macmillan, London

Commonwealth of Australia (1995) National mental health policy. Australia Government Publishing Service, Canberra.

Department of Heath (1995) NHS Responsibilities for meeting continuing Health Care Needs. Department of Health, Leeds.

Dewan , J.M (1989) The clinical impact of the side effects of psychotropics drugs in The limits of biological treatments for psychological Distress, ed  Fisher.S and Greenberg. P.R. Lawrence Erlbaum Associates, Publishers, London.

Elliot C (1994). The family and rehabilitation in Rehabilitation for mental health problems eds Hume C and Pullen I, Churchill Livingstone, London.

Hume.C and Pullen.I (1994). Rehabition for mental health problems an introduction handbook. Churhill Livingstone. London.

Hamilton N.G, Ponzoha C. A, Cutler D.L. & Weigel R.M.(1989) Social networks and negative versus positive symptoms of schizophrenia. Schizophrenia Bulletin 4, 625-633.

Jenny, J (1978) A Strategy for patient teaching. Journal of Advanced Nursing, 3, 341-348.

Jones K and Fowles A.J (1984). Ideas on institutions. Routledge and Keganpaul, London.

Kirkpatrick.H and Landeen J (1999). Rehabilitation for people with enduring psychotic illnesses. In advanced practice in mental health nursing, eds Clinton, M and Nelson S. Blackwell science. London.

Knapp.M, Marks.I, Wolstenholme.J, Beecham.J, Audini.B, Connolly.J, and Watts.V. (1998). Home-based versus hospital based care for serious mental illness, British journal of psychiatric. 172, 506-512.

Leff, et al (1982). A controlled trial of social intervention in the families of schizophrenic patients. British Journal of Psychiatry 131, 121-134.

Leff J. (1992) Problems of transformation. International Journal of Social Psychiatry 38 (1), 16-23.

Lekey, J and Simpkins.R (1994). Employment rehabilitation for disabled people, identifying the issues. Policy studies institute. London.

Morgan,R and Cheadle, J (1981). Psychiatric rehabilitation. Kent paper company. London.

Nikkonen.M (1995). The life situation of a long-term psychiatric patient: some restrictions in, and possibilities of, open care, Journal of advanced nursing, 22, 101-109.

Norman.I and Parker.F (1990). Psychiatric patients’ views of their lives before and after moving to a hostel: qualitative study. Journal of advanced nursing, 15, 1036-1044.

Oliver.M and Barnes. C (1998). Disabled people and social policy. Longman. London.

Palmer-Erbs,V. & Anthony, W. (1995) Incorporating psychiatric rehabilitation principles into mental health nursing. Journal of psychosocial nursing, 33(3), 36-44.

Rumah sakit jiwa pusat, Laporan rumah sakit jiwa pusat semarang, 1998/1999.

No published.

Rorden. WJ & Taft E (1990). Discharge Planning Guide for Nurses . Saunder Company, Philadelphia.

Stein, C.H (1999). Social skills and social networks: making a place for people with serious mental illness. In Advanced practice in mental health nursing, edsClinton, M and Nelson.S. Blackwell science. London.

Taylor JP & Gunn J (1999) . Homicides by people with mental illness : myth and reality.  British Journal of psychiatric 174, 9-14.

Queensland Health, (1994). Queensland Mental Health Plan. Queensland Health, Brisbane.

Vaughn CE and Leff JP (1976). The influence of family life on the course of psychiatric illness, British journal of psychiatric 129: 125-137.

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