Child and adolescent mental health (CAMHS)

Transcription

1 Measuring patient dependency in child and adolescent mental health Paul Abeles, Adam Danquah, Malli Wadge, Peter Hodgkinson, Eleri Holmes Abstract Within the context of child and adolescent mental health inpatient services, a literature review was undertaken to understand the concept of inpatient dependency and how it can be measured. Articles and books relating to patient dependency and its measurement in various contexts were retrieved, and other published measures were identified. It was found that dependency has been defined in many different ways, and various techniques have aimed to quantify or categorize patients dependencies. This article focuses particularly on measures used in adult psychiatry and paediatric services. At present, there is no available established measure of patient dependency in child and adolescent inpatients. This article identifies the need to develop a measure of inpatient dependency that is specifically designed for these services, and outlines a tool that the authors have recently designed. Key words: Dependency Inpatient CAMHS Mental health nursing Patient dependency Psychometric tools Unit resources Child and adolescent mental health (CAMHS) inpatient units provide services for young people who are experiencing complex and severe mental health problems. An inpatient unit has a fixed capacity, which is determined by both the number of beds on the ward and the amount of available nursing time that can be devoted to each patient. CAMHS inpatients all have different dependency levels, which vary widely across presentation such that admitting a highly dependent young person to a unit close to full capacity is likely to overstretch unit resources. In this article, the authors review the concept of patient dependency and how it has been measured in various contexts. They then justify the need for the development of a specific measure of dependency in inpatient CAMHS. Literature review The search was restricted to English language sources from January 1953 to December Electronic databases used Paul Abeles is Clinical Psychologist and Eleri Holmes is Assistant Psychologist, Department of Clinical Psychology, Booth Hall Children s Hospital, Blackley, Manchester; Adam Danquah is Trainee Clinical Psychologist, University of Manchester; Malli Wadge is Senior Clinical Sister and Peter Hodgkinson is Ward Manager, Ward 3, Birmingham Children s Hospital, Birmingham Accepted for publication: August 2007 were MEDLINE, The British Nursing Index, CINAHL, and PsycINFO. In addition, the websites of the Institute of Health Sciences and Public Health Research, the British Library Integrated Catalogue the Royal College of Psychiatrists and the Department of Health were searched. Key words used were: patient dependency, inpatient dependency, dependency measure, dependency tool and dependency needs. The search included any medical- or nursing-related setting and excluded articles which did not appear to describe a system for quantifying or categorizing the dependency of patients. These online searches were augmented by reviewing the reference list of the articles obtained. Articles describing measures of patient dependency were observed to fall into general adult health care, paediatrics, mental health (adult and older people) and just one measure was identified in child and adolescent mental health services (which is the authors area of specific interest). Introduction to dependency measures Patient dependency as a concept is referred to and measured across a range of medical disciplines. The Audit Commission (1992) defines patient dependency as... an assessment of a patient s ability to care for him or herself, for instance, with regard to feeding, personal hygiene and mobility (also see MacGuire, 1988). There is no one, overarching definition of patient dependency. For example, in the context of community nursing, patient dependency has been defined as... the extent to which the patient s level of functional capacity dictates the time required for personal, technical, supportive and educative (district) nursing care (Hopkins and Durand, 1987). Dependency as a function of the amount of nursing that a patient requires is a consistent theme in the literature, but, as Barr et al (1973) have noted, amount of nursing can relate to a number of factors, including time spent by the bedside, severity of condition or the need for specialized treatment. Dependency classification systems need to distinguish between the actual clinical dependency of a patient, and the demands made upon nursing time. Systems that measure patient dependency are defined by James (1991) as those that allocate patients into a number of groups on the basis of their demand for nursing care. This means that in practice, even where the measure of patient dependency is based on severity of clinical status (Gibson et al, 1986), the different levels ultimately correspond to intensity of observation and staff time required. Patient dependency can be seen as a base measure from which many aspects of care and progress can be investigated and on which managerial decisions can be made (Goldstone et al, 1983). In a review of the literature, Escolme and James (2004) 1064 British Journal of Nursing, 2007, Vol 16, No 17

2 MENTAL HEALTH found that many dependency scoring tools had been developed in an acute clinical context and linked patient dependency to nursing workload (Endacott, 1996). Indeed, according to MacGuire (1988a), assessment of patient dependency can be carried out to estimate the workload of a ward or department. However, measures of patient dependency have also been used at various times as a costing tool in paediatric intensive care (Kelly et al, 1999) for costing the intensive therapy nursing in transplant programmes (Gibson et al, 1986), to determine the access of children with complex health needs to appropriate respite services (Escolme and James, 2004) and for assessing the readiness of patients for discharge (MacGuire, 1988b). In the latter paper, MacGuire (1988b) listed fifteen additional uses for the assessment of patient dependency, including use as a basis for the development of individual care plans, monitoring patient progress and research. Dependency can either be measured in terms of the patient s presentation as they would be observed (patient-centred), or by the level of nursing input demanded (nurse-centred approach). Most measures seem to have both nurse-centred and patient-centred elements. Hurst and Howard s (1988) scale contains items using both approaches. An example of a patientcentred measure from this tool is an item on Awareness, which specifies several levels that the patient s awareness can take without specifying any concomitant nursing input. An example of a nursing-centred measure from this scale is an item on Dressing, which is framed entirely with respect to how much help the patient requires to dress. Dependency scales that have been developed in intensive therapy units primarily specify features of the patient s presentation, because of their importance to managing the patient s condition (Gibson et al, 1986; Callaway and Major, 1988). Conversely, in the context of community nursing, Frame and O Donnell (1996) found it more important to clarify patients demands on nursing time, with the aim of convincing purchasers of increased demand and ensuring an equal distribution of workload. Similarly, employed as management tools, it is more often likely that they are nurse-centred as they focus on the demands upon resources (Kelly et al, 1999). However, in the monitoring and evaluation of patient care, measures have been developed that have a patient-centred orientation (Goldstone et al, 1983), while others have a more nurse-centred orientation (Stevens and Groucher, 1985). Review of previous measures A review of published dependency measures in different contexts is provided in Table 1. These measures are now discussed in varying detail and organized into the categories identified in the headings below. Adult health care The first attempt to develop operationally defined categories of patient dependency was made at New York University by Bernstein and his co-workers in Patients were assigned to either of three dependency categories, mildly ill, moderately ill or acutely ill, on the basis of meeting criteria specified for each. Criteria related to the severity of symptoms, general patterns of behaviour and activity and the level of specialist manual or observational skills that the patient required. The categories used are reproduced in Table 2. Although the criteria are vague, this simple step up from a non-objective approach yielded interesting results. After patients had been categorized in accordance with the above, continuous time studies revealed distinct differences between the three groups in terms of minutes of nursing care required by samples of patients from each. Further, these differences were apparent in the amount of professional nursing care required by the samples. In terms of general medical wards, Pardee s (1968) system was designed to assist in predicting staffing requirements by looking at the patients nursing needs and the time taken to meet those needs; conversely, Bryant and Heron (1974a,b) developed a system for monitoring ward workloads which relied primarily on the professional judgement of senior ward nursing staff, who monitored short-term variations in patient-nurse dependency. A monitor system by Goldstone et al (1983) took a number of patient-centred variables into account to produce an index of quality of care, whereas Fabray and Greenhalgh s (1984) costing system enabled nurse managers to identify and cost resources used by patients and thus predict nursing workloads in this way. A nurse-centred measure of dependency by McGratty (1985) was developed to forecast the next day s nursing needs to help maintain maximum efficiency on the ward. Stevens and Goucher (1985) measured levels of care and dependency and recorded these key measures against staffing and hospital activity data in order to ascertain trends in care provision. O Brien (1986) attempted to avoid the rigid categorization of patient dependency systems by placing patients into different time bands, as a way of assessing workload. Levenstam and Engberg s (1993) Zebra system made it possible to both describe the individual patients dependency levels and to calculate the patients requirements of nursing care, both in staffing terms and costs. Several scales have been developed for use in an elderly care setting. Wilkinson and Graham-White s (1980) dependency rating scale assessed the impact of caring for older patients with mental health needs on the nursing time demanded by looking at their level of orientation and behavioural and physical disabilities. In contrast, a patient classification system by MacGuire and Newberry (1984) assessed the level of dependency of an older patient on nursing staff in basic activities of daily living, such as washing and dressing. MacGuire (1988b) also developed a system to assess the readiness of patients for discharge. Rating scales have also been developed for use within intensive care units. Callaway and Major (1988) assessed workload on an intensive therapy unit by rating the patients needs of each bed, so that a bed was rated as having no dependency if it was empty. In addition, Williams (1995) assessed dependency levels in palliative care, including criteria relating to higher needs (e.g. emotional/spiritual and social). Finally, Frame and O Donnell (1996) measured patient dependency for workload management in a community nursing context, where dependency scores were based on frequency of patient visits multiplied by the length of each visit. British Journal of Nursing, 2007, Vol 16, No

3 Table 1. Published patient dependency measures: form and function Place Nurse-centred or Structure Reliability/ Measure developed Use patient-centred of scale Scale output validity Weighting Bernstein (1953) Department of To relate quantity Patient Number of items 3 dependency No Nursing, New and type of not mentioned in categories: York University nursing care to article. mildly ill, patient dependency 3 levels per item moderately ill, acutely ill Pardee (1968) General Classify patients Nurse 3 dependency No medical wards according to categories: nursing needs to minimal, predict staffing moderate, requirements maximal Bryant and General Workload Patient 4 items No Heron (1974a,b) medical wards management 3 6 levels per item Jeevendrampillai Small adult Identifying Patient Questionnaire Points awarded No and Campell psychiatric dependency of comprised of 42 with possible (1979) inpatient unit new long-stay questions divided score of 20 in patients into 5 sections: each section family contact; self care; social skills; activities; interests, use of money, and treatment and care Wilkinson and Elderly Overall demand Nurse 3 sections: Reliability: No Graham-White psychiatric for care on orientation, independent (1980) ward elderly ward behaviour and assessments of 12 physical. pairs of raters Dependency Formula provided compared. Rating Scales for calculating Validity: nursing and (DRS) required ward medical staff assign nursing time patients independently to categories according to time demanded, physical and behavioural dependency. Compared to DRS total scores Goldstone Based on Rush Monitor patient Patient Number of items 5 dependency Validity confirmed by et al (1983) Medicus care not mentioned in categories: discussions with instrument, article. self-care, professionals. Chicago 4 levels per item average care, Inter-rater reliability (Giovannetti, above average measured across four 1978). care, maximum wards: % of questions Developed or intensive care with identical with respect responses and simple to medical, correlation of scores surgical and paediatric units Fabray and General Costing Nurse 4 items 5 care groups: Greenhalgh medical wards 4 levels per item care group 1 (1984) self help, to care group 5 requiring specialling MacGuire and Acute geriatric Statement of Nurse/patient 6 items 4 dependency Inter-rater reliability No Newberry (1984) hospital patients relative 4 levels per item categories: measured by dependence or high (4), comparing The KCT System independence at medium high (3), dependency scores point of discharge general (2), given by various ward low (1) staff: % of identical responses and simple correlations of scores 1066 British Journal of Nursing, 2007, Vol 16, No 17

4 MENTAL HEALTH Table 1. Published patient dependency measures: form and function (continued) Place Nurse-centred or Structure Reliability/ Measure developed Use patient-centred of scale Scale output validity Weighting McGratty (1985) AMI hospitals Workload Nurse 4 dependency No management. categories: NursSys Administrative self-care, low, controls, costing medium and high dependency Stevens and Main hospital Monitor patient Nurse 4 dependency Dependency criteria Yes Goucher (1985) activity: care categories: validated by medical, self-care, professional surgical and minimal, judgement geriatric moderate or (questionnaire study) high dependency Gibson et al Intensive Costing. Patient 3 dependency No (1986) therapy unit Workload categories: low, management medium or high O Brien (1986) Acute areas Workload Nurse Minutes of Patient is Validity of measure No management nursing time per assigned to one inherent in validity of patient per hour. of 5 time intuitive professional Formula bands: judgement provided for 0 4 min per calculating hour up to 45 nursing hours min+ per hour required Callaway and Intensive Workload Patient Number of items Beds are No Major (1988) therapy unit management not mentioned in assigned to one article. of five groups: 5 levels per item 0 (empty), through 0.5 increments to 2.0 (multiple organ failure) Hurst and Psychiatric Evaluate Nurse 6 items Dependency Yes Howard (1988) inpatient unit psychiatric 4 levels per item rating: 1 (low) nursing care. to 4 (high) Workload management MacGuire Elderly care Assessing Nurse 6 items 4 dependency No (1988b) unit readiness of 4 levels per item categories: patients for low, general, The KCT System discharge. medium high Workload or high management, evaluating care, research Meyer and Short-term Workload Nurse 11 items 3 dependency No James (1990) care unit for management. 3 6 levels per categories: disabled Calculating item low, medium children sponsorship or high Levenstam and General Workload Patient 6 items 4 dependency Content validity: No Engberg (1993) medical wards management. 4 levels per items categories: tested by group Costing minimal, discussions with head The Zebra average, above nurses. System average and Inter-rater reliability intensive assessed via comparing nurses individual classifications and the system managers Williams (1995) Palliative care Workload Patient 4 items 4 dependency Reliability assessed by Yes management 4 levels per item categories: comparing low, medium, prospective and high or very high retrospective ratings British Journal of Nursing, 2007, Vol 16, No

5 Table 1. Published patient dependency measures: form and function (continued) Place Nurse-centred or Structure Reliability/ Measure developed Use patient-centred of scale Scale output validity Weighting Frame and Community Workload Nurse Patients assigned Yes O Donnell (1996) nursing management a score along a finite continuum, identifying number of visits a week Furlong and Child Workload Nurse Number of items Content validity based No Ward (1997) psychiatric management. not mentioned in on judgement of inpatient unit Admissions article. nursing team 4 levels per item continual evaluation. Construct validity achieved through cycles of action and reflection. Inter-rater reliability assessed via comparisons of nursing and independent ratings Kelly et al Paediatric Costing Nurse Number of items 4 dependency Concurrent validity No (1999) intensive care not mentioned in categories: assessed by statistical article. low (1) to comparison of results 4 levels per item high (4) with those of established costing tool Escolme and Children with Matching needs Patient Number of items Validity assessed Yes James (2004) complex needs with provision not mentioned in by evaluating in respite care article. appropriateness 6 levels per item of pilot data Key: Place Developed identifies the medical specialism in which the measure was developed; Use summarizes the purpose(s) the measures will serve in that context; Nurse-centred or patient-centred shows whether the dependency criteria measured in the scale are based upon amount of nursing input required to meet patient needs (nurse-centred) or simply descriptions of the patient s presentation/needs (patient-centred); Structure shows the number of items of dependency on which each of the patients are measured, the number of categories the items are organized into and the number of levels within each of these items; Scale output refers to the dependency category or score the patient is assigned once they have been rated on the dependency items; Reliability/validity outlines methods that were used to test the reliability and/or validity of the measure during its development; Weighting shows whether a weighting system has been applied to the measure, i.e. the authors recognize that some aspects of dependency contribute more than others to overall dependency and this is built into the measure. Mental health (adult/geriatric) Hurst and Howard (1988) undertook a study to evaluate nursing care in acute adult psychiatry in their district. The project involved the evaluation of the process of mental health care Table 2. Criteria for classifying patients under the New York classification system Acutely ill Patient manifests a stage of extreme symptoms with marked behaviour patterns or is in a state of unconsciousness. All activity of the patient is completely controlled and continuous specialized manual and/or observational skills are required in therapy. Moderately ill Patients exhibit a stage when extreme symptoms are beginning to subside or when extreme symptoms have not appeared. The patient s activity is partially controlled, his/her behaviour pattern is moderate and periodic specialized manual and/or observational skills are required in therapy. Mildly ill Patients manifest a stage of only a few or mild symptoms with activity only slightly controlled or not at all. His/her behaviour patterns show little or no untoward emotional response and little or no specialized manual and/or observational skills are required in therapy. Reproduced from: Barr et al (1973) and workload assessment. The latter was further divided into an analysis of primary nursing activities and the measurement of patient dependency. To determine patient dependency, they separated nursing interventions into six categories. Each category was divided into a number of levels of dependency, each of which was numbered in accordance with the amount of nursing intervention required at that level the greater the dependency, the higher the number. An example of a category and its associated scoring system is shown in Table 3. In the example, a patient would be assigned a number depending on the amount of supervision required. Similarly, across the other five categories of nursing intervention, the patient would be assigned five more numbers depending upon the amount of intervention required within each category. (Unfortunately, only the observation category above was provided in the paper.) The patient s overall level of dependency is calculated by summing these six numbers. Finally, the patient is assigned to one of four dependency groups, on the basis of the total score. An example of what these calculations looked like in record form was provided by Hurst and Howard (1988) (Figure 1). This information was completed on a daily basis for each patient and information was collated and analysed each month. Data such as these were used in calculations of staffing requirements and were integral to evaluations of both 1068 British Journal of Nursing, 2007, Vol 16, No 17

6 MENTAL HEALTH Table 3. Dependency category and scoring system A: Level of observation Score Patient requires constant observation by one nurse 5 Patient requires frequent observation 3 Patient requires general observation 2 Patient requires norminal observation 1 From: Hurst and Howard (1988) individual patient care and care for each dependency group. Jeevendrampillai and Campbell (1979) identified the dependency of new long-stay patients within a small adult mental health unit. Dijkstra et al (1996) used a phased programme to develop and test the care dependency scale. Their main aim was to develop an easy, short assessment tool that could give a reliable and validated judgement about the patients needs and care dependency status, which could subsequently be used to plan individualized nursing care and for planning interventions to bring the patient to a greater level of independence. The tool was created for use within psychogeriatric nursing homes and facilities for adults with learning disabilities. The scale consists of 16 items relating to nursing care dependency. Each of these are divided into five levels of dependency ranging from complete care dependency to complete independence, producing un-weighted scores ranging from points with a high number representing greater independence. The content, construct and criterion validity and the inter-rater reliability have all been tested, however it has not been used within child mental health units. Paediatrics Meyer and James (1990) developed a way to measure the patient dependency of profoundly and multi-handicapped children in a short-term care unit. The aim was to implement a system whereby staff numbers, skill mix and sponsorship could be accurately matched to the level and types of need currently on the ward. Like Hurst and Howard (1988), a number of dependency categories were identified and divided into numbered levels. Unlike Hurst and Howard (1988), the headings for each category have more to do with patient presentation than specific nursing activities and interventions, but the breakdown of levels is for the most part nurse-centred. Meyer and James (1990) assessment form assessed new patients during their informal visit, in order that appropriate fees could be quoted to sponsoring authorities and an appropriate level of care given.the form was used to assess new patients during their informal visit, in order that appropriate fees could be quoted to sponsoring authorities leading to an optimal level of care. In the context of continuing care for children with complex needs, Escolme and James (2004) developed a tool to identify children with the most complex health needs, flagging up those most in need of respite provision. Unlike many other tools, the Leeds nursing dependency score was not linked to workload management. This, coupled with its remit to highlight the most clinically dependent children, meant that dependency was much more patient than nurse centred. Key health-related categories were divided into different levels of dependency, which were assigned scores weighted to reflect the amount of dependency. Weighting was based on factors such as the frequency and severity of health needs; greater weightings reflecting greater need. Table 4 shows one example of a health-related category, constituent levels of dependency and their associated scores. Clinical knowledge and experience was used to make judgements about the different weightings, as well as Leeds continuing care criteria (Leeds Health Authority, 1996). In practice, the tool is used in initial assessments for access to respite provision and the authors suggest that it can measure change in needs during provision. The validity of the tool was tested with a sample of 50 children, to assess whether categorizations of complexity matched perceived levels of complexity. Revisions and additions were made to the tool in the light of this analysis, including changes to scoring and a supplementary measure of social need. A similar exercise was later carried out in a respite care unit in a neighbouring authority. In terms of assessing concurrent validity, the tool has been used in parallel with and its results compared with continuing healthcare criteria. Reliability has been checked by monitoring the consistency with which the tool has identified those with the most complex needs over the two and a half years for which it has been in use (as well as through the comparison of results generated across sites, Figure 1. Patient dependency record from Hurst and Howard (1988). Ward: acute Dependency ratings Total : Rating Date: 26/3/87 >16* : : : 2 <5 : 1 Name A B C D E F total rate John Smith Ann Jones * Article typographical error (from current authors reading of article). Changed from 15 to 16 Table 4. Example of a health-related category in the Leeds nursing dependency score Airway management Score Medical condition 0 no airway problem Symptomatic airway 1 Problems Occasional oral/ 2 nasopharyngeal suction Frequent oral nasopharyngeal suction 5 intermittent airway at risk Tracheostomy stable only needing 15 Routine changes Unstable tracheostomy 20 Unstable airway Ventilation From: Escolme and James (2004) British Journal of Nursing, 2007, Vol 16, No

7 above). Refinement of the tool has been constant, in the light of these ongoing analyses. A more recent measure for use within paediatric intensive care was developed by Kelly et al (1999), examining the cost of service provision by the amount of nursing time required by the patient. Inpatient CAMHS Furlong and Ward s (1997) paper describes the only reported study which attempted to develop a measure of patient dependency relevant to the CAMHS inpatient unit. The authors were concerned with quality assurance in nursing, in particular, addressing increasing interest in providing high standards of patient care through different combinations of nursing skills and cost-effective use of resources. The researchers sought to construct a tool that would enable nurses to calculate the number of staff and skill mix needed for certain periods of work and for specific (unit) dependency levels. In order to make these calculations, concurrent measures of patient dependency, skill mix and quality of care were taken, so that the balance of patient dependency and skill mix that produced optimal quality of care could be ascertained. In order to make these calculations, a measure of patient dependency that could assess individual levels of patient dependency and be summed to gauge the unit s total level of patient dependency at any given time was required. Furlong and Ward (1997) noted that Meyer and James (1990) provided the only available framework for measuring patient dependency in young people, but their client group of profoundly disabled children required different assessment to those admitted to the CAMHS inpatient unit. Categories for measuring patient dependency with regard to evaluating mental health nursing care identified by Hurst and Howard (1988) were regarded by the authors as being too adult-focused. For the reasons above, Furlong and Ward (1997) decided to develop their own measure of patient dependency. Information about nursing activities and interventions was collated, discussed in depth and categorized. This process was informed by Maslow s (1954) hierarchy of needs, which recognizes that there are different categories of human need, ranging from basic (e.g. physiological needs, such as hunger) to higher, more abstract needs (such as selffulfilment). Two examples of dependency categories outlined in the paper were Verbal and physical intervention and Table 5. Examples of patient dependency hierarchies Level Verbal and physical intervention Interpersonal activities 1 Simple instruction is sufficient Interacts age-appropriately to avoid danger 2 Needs to be moved away Responds mostly in an agefrom danger appropriate way 3 Needs to moved away from Communicates agedanger repeatedly inappropriately 4 Needs to be physically contained Does not develop to avoid danger interpersonal relationships From: Furlong and Ward (1997) Interpersonal activities. Table 5 displays these categories and their constituent levels of dependency or dependency hierarchies (Furlong and Ward, 1997). Staff at all grades analysed the dependency categories that had been generated and provided definitions for the different levels of dependency within a category. The number of levels within a category was set at four to cover a range of dependencies, while avoiding a middle rating. The levels were assigned ascending numbers from one to four, which represented the corresponding increasing dependency levels. From the outset, Furlong and Ward included staff working in the unit while developing the measure so that the categories and their levels of dependency were familiar and meaningful to those who would be using the measure in practice. Furlong and Ward s measure was piloted on the inpatient unit at Park Hospital for Children, Oxford. Each patient on the ward was rated by at least two nurses using the measure. Completing the scale consisted of reading through the various categories and selecting a level that best reflected the level of dependency of the patient. An individual patient s dependency level was calculated by summing the numbers selected from each patient dependency hierarchy, and the unit s overall level of dependency could be calculated by the further summation of these individual dependency scores. The content validity of Furlong and Ward s measure was served by having nursing teams involved from the start, who devised items and were responsible for ongoing refinements to the content and format of the scale. The inter-rater reliability (the similarity between the scores of different nurses rating the same child) was assessed by comparing the scores of nurses with those of independent raters, who were staff that were not responsible for the day-to-day care of the patients. Further investigations into the measure s reliability were made by comparisons between the scores of different combinations of raters, and between established staff and new staff, who had not been employed when the measure was developed. The scale was revised with regard to unclear definitions and overlapping categories which had been identified by staff during piloting. On completion of the pilot study, the authors had developed a measure of patient dependency informed by expert opinion and refined with respect to testing in vivo. Using the measure in practice over a period of months, alongside measures of quality of care and skill mix, meant that Furlong and Ward could demonstrate the detrimental effect that high dependency had on quality of care, and pinpoint times at which particular skill mixes were required. Most importantly, Furlong and Ward realized that their measure could be used to assess the dependency of a young person before admission. In this way, the ability of the unit to accommodate a referred child could be assessed with regard to his or her dependency and the total dependency of all of those already on the ward. Being the only measure to date that had been developed to specifically measure patient dependency in an inpatient CAMHS context, Furlong and Ward s measure was an obvious resource to develop and integrate into the authors current project. Unfortunately, the scale was not provided in the article and attempts to obtain it from both the authors and the hospital where the research was carried out have proved unsuccessful British Journal of Nursing, 2007, Vol 16, No 17

8 MENTAL HEALTH Development of CAMHS-AID From the literature it is evident that there is no current inpatient dependency tool available for young people with mental health problems. The authors feel that there are important lessons to be learned from the literature which has been presented in this review. There are many good points which can be used to inform the development of a CAMHSspecific dependency measurement tool. Some of the models discussed have been patient-centred, for example Bernstein (1953), Goldstone et al (1983) and Escolme and James (2004). Others have been more focused on the nursing role as can be seen in Pardee (1968), Fabray and Greehalgh (1984) and Furlong and Ward (1997). It is the authors opinion that the use of a nurse-centred model is appropriate as most dependency concerns the amount of time nurses spend engaged on direct and indirect nursing care. The use of a patient-centred model allows for the recognition of the uniqueness of each nurse and patient interaction. MacGuire and Newberry (1984) are the only authors who were found to use a combined focus. The authors feel that in the CAMHS arena, a combined model should be the basis for the development of a tool. This would allow a holistic approach to measuring care, which best reflects clinical reality in which the care is given. As CAMHS is such a specialist area, any dependency tool development would benefit in using clinical opinion to create a new tool from the outset, as described by Furlong and Ward (1997). Further, several authors have used clinical opinion in assessing reliability and validity (MacGuire and Newberry, 1984; Stevens and Goucher, 1985; O Brien, 1986; Dijkstra et al, 1996). The authors of the current project believe that the most logical approach to developing a new tool would be the inclusion of expert clinical opinion from the outset, thus allowing an informed and realistic tool which is validated by those with experience in the field. The authors are in the process of developing such a tool for use within inpatient CAMHS, informed by the literature as discussed above and building on this. In line with McWilliam and Wong (1994), the hidden work factors have been considered, such as the effect of young people on the therapeutic milieu, the interactions between staff and young people, care planning, liaison work and therapeutic work by other individuals, which are not specifically mentioned in Furlong and Ward s (1997) measure. This tool, the CAMHS assessment of inpatient dependency (CAMHS-AID) was generated with the inpatient CAMHS staff group on two inpatient units. These items were organized into modules that had a common theme and which, between them, addressed all areas within the CAMHS nursing workload (young people s basic needs, amount of supervision required, their social communication skills and the amount of liaison work required). Each of the 47 items was derived and phrased into levels according to an ordinal scale of 0 4, usually reflecting the different amounts of nursing input required to manage the patient with regard to the area of dependency. The rater is required to tick a box on the form which indicates the level which best represents the needs of the patient in that area. To aid this decision the rater is provided with a general description Table 6. Example CAMHS-AID item from basic needs General Specific Example 0 Fully independent in personal care 1 Requires minimal By one Young person is able to meet their intervention person personal care needs with a few verbal prompts and/or minimal assistance buttons, laces 2 Requires moderate By one Young person able to meet personal intervention person care needs with frequent verbal prompts can put on two garments, wash hands, recognizes need to defecate/urinate 3 Requires intensive By one Young person unable to meet one intervention person third of personal care needs without assistance, but able to recognize need to eliminate/attend to basic hygiene needs 4 Requires intensive By more than Young person always unable to meet intervention one person personal care needs and requires assistance and example as well as more detailed instruction as to what to do (see Table 6). The sum of the items within each of the CAMHS-AID s modules creates a dependency profile. A computerized scoring system has also been devised to ensure the most accurate estimation of patients dependency. Weighted scores were devised by estimating how long it would take in hours per day for each level of the task to be completed. The intensity of the activity was also examined by determining whether it was a task which could be completed alongside others (e.g. supervising patient who is at risk of self harm, can also attend to any dietary needs), or whether it would need to be done on its own (e.g. liaison work, such as telephoning a family). It was also decided that some tasks would also instantly put a patient on a one-to-one basis, whereby one member of nursing staff is exclusively designated to spend time with a young person all the time. These factors determine how the scale is scored. The CAMHS-AID has been completed by many CAMHS nurses in various levels of seniority and usually takes about minutes to complete initially, but when an individual is familiar with the instrument, about 5 10 minutes. In the authors review of available measures, only half published reliability and validity data, but this is regarded as a key feature for an instrument to be used to inform clinical management. Thus, there have been various studies conducted to evaluate the CAMHS-AID s reliability and validity. In an initial exploratory study (Abeles, Hodgkinson, Wadge, unpublished manuscript, 2002), 20 nurses across two CAMHS inpatient units completed 162 questionnaires for 15 inpatients. Comparison of scores with the clinical opinion of each patient s dependency on a three-point scale (high, medium, low dependency), retrospectively rated by the nurses showed broad agreement between the initial version of the scale and clinical opinion. Frequency graphs were computed for each item in terms of the total number of responses for each level of the item. If a level within an item had received a disproportionately low number of responses, then the criteria to rate at that level were reviewed to assess whether they were too stringent. If a level within an item had received a disproportionately high number British Journal of Nursing, 2007, Vol 16, No

9 of responses, then the criteria to rate at that level were reviewed to assess whether they were too lax. Additional comments, queries or suggestions on the completed questionnaires were used to make useful additions and amendments to the scale in order to improve issues such as clarity and comprehensiveness. In the second study by Hodgkinson et al (2005), between five and ten nurses filled out CAMHS-AIDs for each of four patients on the ward, producing 27 completed questionnaires and they made clinical ratings at the same time. There was a strong positive correlation between the two variables with high CAMHS-AID scores associated with high clinical-opinion ratings. To evaluate the CAMHS-AID s content validity, questionnaires were given to 86 substantive nurses from Birmingham, Manchester and London who were asked to rate each item of the CAMHS-AID for how clear the items were and how well they reflected practice (Abeles, Holmes, Wadge, Hodgkinson Danquah, unpublished manuscript, 2007). Nearly all of the items were given a score of 4 or 5, with a score of 5 representing very clear and easily understood and good match for reflection of practice. A study to evaluate the CAMHS-AID s reliability and validity is nearing completion with promising initial data. The inter-rater reliability of nurses rating in-patients in different units around the country has been collected along with their clinical ratings of dependency. In addition, the CAMHS-AID has been completed for 58 students attending at a residential schools and CAMHS-AIDs are being collected from patients on paediatric wards. Lower CAMHS-AID scores were found in the residential school population relative to the inpatient normative sample, and it is expected that patients on Paediatric wards will be rated as having higher (CAMHS) dependency than the residential school sample but lower than the CAMHS inpatient sample. Conclusion Like any other medical specialty, inpatient CAMHS patients present the finite resources of an inpatient unit with differing KEY POINTS Patient dependency is an assessment of a patient s ability to care for him or herself, for instance, with regard to feeding, personal hygiene and mobility. There are a limited number of tools that measure patient dependency. These have been developed over 50 years and for varying care contexts, with different degrees of reliability and validity. Tools have been used to measure patient dependency using either a nursingcentred or patient-centred focus. Patient dependency can be objectively measured by rating participants using standardized criteria. Although patient dependency has been measured in various medical contexts there is a lack of an appropriate and specific dependency rating scale for use in child and adolescent mental health inpatient units. A brief description of a novel instrument developed to measure dependency in child and adolescent mental health inpatient services that has been developed by the authors. levels of dependency and an ability to measure those specific needs will improve patient care. However, this review of the literature demonstrates that, although dependency measures exist in various areas of healthcare, there are no appropriate existing tools that are available for this specialist area. Therefore, the authors have developed the CAMHS-AID, a dependency measure that has been specifically developed for inpatient CAMHS. 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