Dean Blevins

The Influence of Cultural Diversity on End-of-life Care and Decisions

The heath care system in the United States is based on specific cultural beliefs that are sometimes inappropriate with groups that have different belief systems. These cultural differences can be seen in various end-of-life situations. To familiarize providers with some of the ways that culture can influence end-of-life care and decisions, the authors focus on the following three individual characteristics shown to be important in the literature: age, ethnicity, and gender. The article contains a broad overview of the (a) documented differences in the cultural interpretations of the ethical meta principles (e.g., autonomy and respect), (b) provision of medical service in general and pain management in particular to different groups, and (c) attitudes toward various end-of-life interventions and the use of advance directives. Finally, the authors summarize guidelines for making end-of-life care more culturally sensitive, which emphasize that each person must be interacted with as a unique individual.

Translating clinical training into practice in complex mental health systems: Toward opening the 'Black Box' of implementation

BackgroundImplementing clinical training in a complex health care system is challenging. This report describes two successive trainings programs in one Veterans Affairs healthcare network and the lessons we drew from their success and failures. The first training experience led us to appreciate the value of careful implementation planning while the second suggested that use of an external facilitator might be an especially effective implementation component. We also describe a third training intervention in which we expect to more rigorously test our hypothesis regarding the value of external facilitation.ResultsOur experiences appear to be consonant with the implementation model proposed by Fixsen. In this paper we offer a modified version of the Fixsen model with separate components related to training and implementation.ConclusionThis report further reinforces what others have noted, namely that educational interventions intended to change clinical practice should employ a multilevel approach if patients are to truly benefit from new skills gained by clinicians. We utilize an implementation research model to illustrate how the aims of the second intervention were realized and sustained over the 12-month follow-up period, and to suggest directions for future implementation research. The present report attests to the validity of, and contributes to, the emerging literature on implementation research.

Ministers’ Perceptions of Depression: A Model to Understand and Improve Care

While depression is a significant worldwide health problem, fewer than half of individuals seek care. Faith-based communities may play an important role in improving the knowledge of and linkage to depression care. Focus groups of Caucasian and African-American clergy were conducted to explore these issues. Using a grounded theory approach five themes emerged, including explanatory models of depression, barriers and facilitators to care, and recommendations for involving religious communities. A model of depression care pathways was constructed that integrates secular and spiritual approaches. The findings highlight the need for targeted interventions to build trust between clergy and mental health professionals.

Predicting implementation from organizational readiness for change: a study protocol

BackgroundThere is widespread interest in measuring organizational readiness to implement evidence-based practices in clinical care. However, there are a number of challenges to validating organizational measures, including inferential bias arising from the halo effect and method bias - two threats to validity that, while well-documented by organizational scholars, are often ignored in health services research. We describe a protocol to comprehensively assess the psychometric properties of a previously developed survey, the Organizational Readiness to Change Assessment.ObjectivesOur objective is to conduct a comprehensive assessment of the psychometric properties of the Organizational Readiness to Change Assessment incorporating methods specifically to address threats from halo effect and method bias.Methods and DesignWe will conduct three sets of analyses using longitudinal, secondary data from four partner projects, each testing interventions to improve the implementation of an evidence-based clinical practice. Partner projects field the Organizational Readiness to Change Assessment at baseline (n = 208 respondents; 53 facilities), and prospectively assesses the degree to which the evidence-based practice is implemented. We will conduct predictive and concurrent validities using hierarchical linear modeling and multivariate regression, respectively. For predictive validity, the outcome is the change from baseline to follow-up in the use of the evidence-based practice. We will use intra-class correlations derived from hierarchical linear models to assess inter-rater reliability. Two partner projects will also field measures of job satisfaction for convergent and discriminant validity analyses, and will field Organizational Readiness to Change Assessment measures at follow-up for concurrent validity (n = 158 respondents; 33 facilities). Convergent and discriminant validities will test associations between organizational readiness and different aspects of job satisfaction: satisfaction with leadership, which should be highly correlated with readiness, versus satisfaction with salary, which should be less correlated with readiness. Content validity will be assessed using an expert panel and modified Delphi technique.DiscussionWe propose a comprehensive protocol for validating a survey instrument for assessing organizational readiness to change that specifically addresses key threats of bias related to halo effect, method bias and questions of construct validity that often go unexplored in research using measures of organizational constructs.

Partnering With Communities to Address the Mental Health Needs of Rural Veterans

PURPOSE Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). METHODS Three community stakeholder groups-clergy, postsecondary educators, and criminal justice personnel-are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center-based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. FINDINGS One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2-hour workshop and an intensive 2.5-day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. CONCLUSIONS While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.

Psychosocial issues near the end of life : a resource for professional care providers

Although numerous books have been written on the physical and practical aspects of providing services to people who are dying, relatively little has been written on the psychological, spiritual, and interpersonal issues that arise. Until now, psychologists and mental health professionals who work with the dying and their loved ones have had no resource to guide them toward empirically supported practices that can improve quality of life. This book fills that gap. Improving quality of care requires an interdisciplinary approach, and the contributors to this volume bring multiple perspectives to bear on the topic. Chapter authors from both research and clinical perspectives cover how the end-of-life environment has changed over time; the kinds of decisions that need to be made; the role of psychologists in end-of-life care; cross-cultural considerations; assessment; legal issues; practical caregiving; misinformation about depression and hopelessness; and the respective roles of caregivers and hospices. The final chapter by the editors lays out a blueprint for future research, care, education and policy. This book provides a model for the important role that psychologists can play in ensuring that end-of-life care balances physical care with psychosocial and spiritual care.

Older Adult Representation in the Counseling Psychology Literature

The increasing older adult population has implications for the training and practice of counseling psychologists because of the fields avowed dedication to lifespan development. The present study examined the degree to which older adults were represented in articles in the Journal of Counseling Psychology and The Counseling Psychologist from 1991 to 2000. Several issues were examined: age-based characteristics of samples reported, changes in these characteristics over time, whether articles including multiple studies involved older participants, and degree of attention to older adults in theoretical articles. Results are discussed in context of the traditional definition of counseling psychology, what counseling psychologists have to offer older adults, and the implications for the training of counseling psychologists with expertise in older adult issues.

Public Policy and End-of-life Care

End-of-life public policy has the potential to affect everyone. The purpose of this article is to provide an overview of recent significant policy activity. The authors begin by reviewing the Medicare and Medicaid hospice benefit and the Patient Self-Determination Act, highlighting state-level developments, and noting significant court cases. They then discuss common concerns with Medicare, advance directives, hospice, and pain management and provide proposed remedies for the concerns. The article ends with recommendations for advocacy by behavioral and social science professionals.

Evaluating a community-based participatory research project for elderly mental healthcare in rural America

The purpose of this evaluation was to explore the collaborative nature of partners in a rural mental health program for the elderly, and to test an adapted method of assessing the collaborative process. Sixteen collaborative partners were interviewed to explore ratings of collaboration across 6 domains identified as critical to participatory research. Results indicate that the context of rural Missouri and uniqueness of the program necessitated an approach to collaboration that began with a top-down approach, but greater community responsibility developed over time. Partners recognized the efforts of the program’s directors to seek input. Most were satisfied with their roles and the degree of success achieved by the program, although several wanted to have more input in the future in some domains, but not in others. Interviews revealed numerous barriers to achieving sustainability. Methods to improve the assessment of collaboration are discussed and areas for improvement are offered.

Family Relationships, Mental Health, and Injury Among OEF/OIF Veterans Postdeployment

As the number of military service personnel who have served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) approaches 3 million, concern mounts about potential negative effects of long and multiple combat-related deployments on military families. This study used secondary analysis to compare the mental health status and family functioning of postdeployment National Guard members with and without children. Among guard members with children, comparison was made between those who did and did not report behavioral problems in their children. Finally, the study identified how mental health status and deployment experiences (including injury) were jointly and uniquely associated with childrens problems. Veterans with children were more likely to be married and older; to endorse more symptoms of depression, interpersonal violence, and anger; and to indicate lower satisfaction with family and social relationships than veterans without children. Veteran parents reporting childrens problems had greater mental health symptoms, including depression and anxiety, and lower satisfaction with family and social relationships. Regression modeling indicated that veterans’ age, reported sleep problems, and mental health issues were independent risk factors for childrens problems.