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Quality and clinical outcomes in applied relaxation

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VOL: 98, ISSUE: 11, PAGE NO: 39

Adrian Childs-Clarke, RMN, DipN, is BICS coordinator, department of psychology, Northwick Park Hospital, Harrow;Tracey Hillier, RGN, RMN, is professional nurse adviser, Tatchbury Mount Hospital, Southampton;Maureen Lynch, RGN, RMN, and Linda McDougall, RMN, are both cognitive behaviour therapists, Royal South Hants Hospital, Southampton

Clinical governance is a framework that allows nurses and other health care workers to monitor and improve the quality of the services they provide. Quality services are not only clinically effective but also take into account accessibility, social acceptability, relevance to need, equity and efficiency (Maxwell, 1984).

Clinical governance is a framework that allows nurses and other health care workers to monitor and improve the quality of the services they provide. Quality services are not only clinically effective but also take into account accessibility, social acceptability, relevance to need, equity and efficiency (Maxwell, 1984).

Routinely gathering information for audit and evaluation requires the help of administrative and audit staff, so when resources are under pressure one solution is to use a minimal data set.

A previous audit using limited resources and a minimal data set showed that it was possible to evaluate a nursing service (Childs-Clarke and Wagstaff, 1996). However, its limitations included the restricted availability of data as patient feedback outside clinical outcome was not analysed.

One way to resolve this is to carry out periodic retrospective audits (Sale, 1996). These have a number of features, including:

- The extraction of data retrospectively from case records;

- Post-care interviews conducted by inviting patients, on completion of therapy, to return to discuss their experiences;

- Post-care questionnaires given to patients on discharge.

In a previous study on anxiety management groups, which was reported in two separate articles, patients were invited to be interviewed again for evaluation purposes (Childs-Clarke et al, 1989; Cadbury et al, 1990). In addition to evaluating the long-term effectiveness of the groups, a number of other areas were examined.

This provided information on the helpfulness of the groups, but the questions did not include Maxwell's other criteria, namely accessibility, social acceptability, relevance to need, equity and efficiency. This paper describes the development of this work to include patient's responses to other areas of the service.

Method
All patients were referred to a cognitive behaviour therapy (CBT) nursing service based in a mental health unit on a district general hospital site. A total of 31 patients were assessed as suitable for applied relaxation therapy (Ost, 1987); 18 women and 13 men. The average age was 36.7 years, ranging from 22 to 57.

A semistructured interview was developed to establish the type of anxiety present. This formed the basis of each assessment. Patients were accepted if they fulfilled the diagnostic criteria of the American Psychiatric Association (1987) for one of the following problems: generalised anxiety disorder, panic disorder, simple phobia, somatisation disorder, agoraphobia and social phobia.

Patients who fulfilled the criteria for blood-injury phobia and obsessive compulsive disorder were excluded because the researchers felt that the effective management of these problems relied on interventions not included in the applied relaxation package. For similar reasons, patients were not accepted if they had a coexisting psychosis or significant depression. Fourteen patients had focal and health anxiety, such as phobias, and 17 had free-floating anxiety, such as generalised anxiety and panic.

All patients completed the Crown-Crisp Experiential Index (CCEI) as part of their assessment (Crown and Crisp, 1979). This is a 48-item questionnaire with six subscales to measure anxiety and other neurotic symptoms. Patients completed the questionnaires before and after the group therapy, and also at follow-up.

The final follow-up visit included a semistructured interview based on an earlier interview (Childs-Clarke et al, 1989). This covered a range of subjects in line with Maxwell's (1984) criteria (see Box 1, overleaf).

Patients were asked to comment on each section. On completion of each, a closed question was asked and patients were invited to rate the service on a scale ranging from zero to eight, with high scores indicating the greatest dissatisfaction.

The group
The 31 patients in the group followed a standardised programme. Five dropped out before the third session and seven left before the fifth. The data analysed relates to 19 patients who completed an adequate trial of therapy. There were nine sessions and their content followed the format laid down by Ost (1987).

Results
Clinical effectiveness

The clinical outcome of the participants is shown in Table 1. The results of an earlier study, in which a group of patients with free-floating anxiety was followed up after participation (Childs-Clarke et al, 1989), are shown for the purposes of comparison.

The results of this study are comparable with the results of other patients treated in groups for anxiety. The CCEI scores were collapsed to obtain a single mean score. The clinical improvements were maintained during the follow-up period. There were no statistical differences between discharge and follow-up scores.

Quality measures

- Access

Patients were asked if they would have preferred a different venue. Eight referred to the stigma of having to attend the department of psychiatry and patients found it difficult to get to. The most common feedback related to parking problems.

- Social acceptability

The time the group was held was not a general problem. Some patients commented that they would have preferred an evening group if they had been working.

Twelve felt that the interviewer understood their problems. When asked whether the type of help provided had been explained and a choice of help offered, a number of patients said it had been fully explained. However, six said they had not been given any alternative to group therapy.

Six patients felt that their first appointment had been stressful, but only one felt that this could have been improved by the provision of more information in advance.

The size of the group ranged from three to eight patients. Some found small groups easier to talk in, while others would have preferred larger groups because they enabled wider participation.

Gender mix did not appear to be a problem, but some patients felt uncomfortable when others dropped out.

- Effectiveness

Patients had mixed views on handouts, with some wanting a wider range of information, such as on occupational stress, and others wanting it to be provided earlier. Nine said the handouts had been helpful. When asked if they would be happy to share them with a friend who had similar problems, six said they would.

Eight were satisfied with the duration of the group, but some commented on a lack of continuity because of the Easter break. Only one would have wanted booster sessions, and 11 were satisfied and found the group helpful.

Their comments followed three strands. If group attendance fell below three, it was too small; if one person dominated the session, this was unhelpful. With regard to the environment, the group felt that the room was too cold and sterile, but that changing it would have been disruptive.

Discussion
The results suggest that the relaxation groups were clinically effective, but other service modifications could be based on these results. An earlier study evaluated a CBT nursing service at the same hospital (Childs-Clarke and Wagstaff, 1996). It included an examination of the uptake of therapy and rates of non-attendance. This led to speculation about the cause. There were two possibilities: site accessibility and the stigma of attending the department of psychiatry.

As a consequence, questions on acceptability and accessibility were included in this survey. The results suggest that both psychiatric stigma and accessibility play a part in uptake. One solution could be to base the services in the community.

The therapy setting is important. In busy locations, it may be difficult to find an available room. Although good therapy can be conducted in a variety of environments, an appropriate setting can improve the process. Nursing care should be delivered in as stable an environment as possible, with decor that is not too clinical and a welcoming environment.

Twelve participants completed the course of therapy, so the question of attrition needs to be examined when looking at the efficiency and economy of groups. Patients commented that they had not been given any options other than group therapy. With long waiting lists for individual therapy, it may be tempting to offer only group sessions. This may account for the absence of choice in this case.

As this study shows, patients are aware when others drop out and are affected negatively by it. It is not clear what happens to those who drop out, but if they simply present again this could incur additional costs.

We recommend that nurses who run groups pay attention to the following issues: the setting of the group; the stability and surroundings of the room; and adequate preparation of each individual to reduce attrition.

For nurses who want to monitor and improve services, we have shown that it is possible to audit them with limited resources. Any audit should include patient feedback, not only to assess clinical outcomes but also to focus on key quality issues. This should follow on from earlier audits: in our case, questions about acceptability and accessibility arose from an earlier clinical audit review.

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