Establishing an NP-Led Day Treatment Facility in Bessemer Alabama

Establishing an NP Led Wellness and Recovery Center for Deinstitutionalized Individuals Historically, nursing, and medicine professions have been loath to utilize tools commonly linked with mercenary aspects of business, such as market research and decision analysis. In the contemporary health care setting, however, consumers hold numerous options for care providers. The division of the market or market segmentation into different subgroups allows the determination of target markets and the buildup of marketing policies specific to the needs and interests of the selected subgroups.

Market analysis allows the identification of policies for nurse practitioners to enhance their practice in a way that centers on the interests and needs of the selected market. While scores of the nurse practitioner's dream of operating their own businesses, those that have set up their own practice understand that it requires a compelling passion for owning a business, and for the profession. A nurse practitioner is an advanced practice nurse who offers care to patients.

A nurse practitioner conducts comprehensive and focused physical assessment, treatment and diagnose acute sicknesses and injuries. About fifteen percent of all nurse practitioners are in their own private practice. This paper explores the effects of deinstitutionalization and reduction of bed capacity in psychiatric wards, and assesses NPs perception of the value of establishing their own business, and the role of a nurse practitioner in minimizing and addressing the effects of deinstitutionalization.

This work investigated whether establishment of community mental health facilities can moderate the link between deinstitutionalization, homelessness, suicide, stigma, social isolation and other factors linked to deinstitutionalization. A case study approach with qualitative and quantitative analysis was employed, and the findings indicated that deinstitutionalization following closure of state-run psychiatric facilities in Alabama increased the suicide rates, homelessness, stigma, inadequate treatment and social isolation. Results indicated that substantial community mental health resources prevent the negative effects of deinstitutionalization.

In conclusion, closing state-run mental health facilities increases suicides, stigma, inadequate treatment, social isolations, diseases such as TB for mental health patients living in the streets, social isolation, but a rise in community-based mental health centers and privatization of the mental health market are promising and reduces the negative effects of deinstitutionalization.

TABLE OF CONTENTS Abstract Introduction 5 Project Organization 7 Problem Statement 8 Background Information 9 Purpose of the Project 11 The Nature of the Project 13 Research Questions 15 Theoretical Framework 15 Figure One: Conceptual Framework Model 17 Definition of Key Terms 18 Scope and Limitations 19 Summary 20 Chapter 2: Literature Review 20 Introduction 20 The Role of Nurse Practitioners 22 Deinstitutionalization 23 Nurse Practitioners as Business Owners 25 Conclusion 27 Summary 28 Chapter Three: Methodology 28 Introduction 28 Population and Sample 36 Data Collection Instruments 36 Ethical and Legal Considerations 37 Data Analysis 37 Validity 38 Methodology Appropriateness 39 Feasibility and Appropriateness 40 Summary 40 Chapter Four: Findings 40 Introduction 40 Data Analysis 41 Conclusion 43 Chapter Five: Discussion 43 Introduction 43 Interpretations and Inferences from the Findings 44 Implication of Analysis for Leaders 46 Recommendations 46 Conclusion 47 Reference List 48 Chapter One Introduction Deinstitutionalization burdens the community given the lack of sufficient resources and infrastructure to house persons who require permanent care for psychological, neurological conditions and other behavioral disorders.

Complexity to adjust to community life for people with mental health problems calls for help from social workers and psychiatric rehabilitation, which fosters recovery and hope for patients. Deinstitutionalization provides prospects for Psych/MH Nurse Practitioners to set up their own facilities to care for deinstitutionalized mental health patients. Psych/MH Nurse Practitioners offer primary health care to persons with mental health issues in different settings. Their roles stresses of clinical leadership, research, consultation and expert clinical practice.

The objective of deinstitutionalization is to enhance quality of life and treatment of people with mental disorders. The actuality of deinstitutionalization has turned it into a polarizing concern. While some studies report that deinstitutionalization leads to positive upshots, others confirm that people living in homes or other independent community settings hold great deficits in crucial facets of health care provision.

Opponents of deinstitutionalization indicate that scores of patients move from inpatient mental health hospitals to residential homes or nursing homes that are less equipped or staffed to achieve the requirements of the mentally ill. In several cases, the act of moving patients from mental health institutions shifts the care burden to families. While the debate for deinstitutionalization goes on, healthcare professionals, advocates for mentally ill persons and families calls for augmented accessibility and availability of permanent psychiatric in-patient and intermediate care for persons requiring more structured care setting.

Scores of experts indicate that through enhancing community-based programs and extending in-patient care to satisfy the requirements of mentally ill people, the state will attain enhanced treatment upshots, better life quality and augmented access to mental health care. To achieve the goal of deinstitutionalization, a wellness and recovery center for deinstitutionalized individuals is paramount. Such establishments provide detailed services created to support people with mental health issues. These establishments offer skill building activities and curriculum, community-founded peer support and family education.

Expectation of wellness and recovery centers is for patients to obtain enhanced overall wellness and health, to set and attain personal objectives independently within the community or within the patients' families. Wellness and recovery centers require the services of nurse practitioners, nurse technicians and social workers to provide psychiatric assessments, management of medicine, general care, supervision of in-patients and on-site patients and follow-up care. Nurse technicians monitor the physical wellness of patients.

All these services have the potential to address issues linked to the ongoing deinstitutionalization in the state of Alabama. Nurse practitioners have the potential to examine their own goals and visions for developing individualized practice models. Aspects that affect the healthcare system that include electronic record maintenance, technology, efficient payment systems, high cost, lack of access to health care and other variables that influence health maintenance, illness prevention and health promotion have formed novel and exciting prospects for nurse practitioners that allows them to establish their own practices.

In light of the issues regarding deinstitutionalization and the closure of state-run psychiatric facilities, which is likely to create more problems in the community, Psych/MH Nurse Practitioners can assist curbing the increasing gap left by state-run psychiatric services and facilities through setting up a wellness and recovery center. Project Organization Chapter One of this study covers the statement of the problem, background to the study, the purpose of the study, the significance of the study, the nature of the project, research questions or hypothesis and theoretical framework.

Chapter one also covers the scope and limitations of the project, definitions of significant terms besides providing a summary of the entire chapter. Chapter two covers the literature review and provides information that guides the research study, and it offers a synthesis of literature and research studies on the role of Psych/MH Nurse Practitioners and how a nurse practitioner can establish his/her own practice. This section ends with a coherent conclusion summarizing major points, and details how the literature review contributes to the research topic.

Chapter 3 covers the methods used in collecting the research data. This section starts with a concise introduction, project design, instruments used in data collection, target population, sample and sampling procedures, data collection, management and data analysis, validity and reliability of the methodology used, appropriateness of the methods, besides a practical summary of the entire chapter. Chapter four covers the research findings through putting into consideration the demographics, research questions, data analysis procedures, and reliability and validity of the research methods.

Chapter 5 provides a coherent discussion and interpretation of the findings, implications of the study, recommendations and culminates with a summary highlighting the purpose of the project, major findings and recommendations for future research. Problem Statement Statistics from National Alliance on Mental Health Illness indicate that out of the 4.7 million people in Alabama, 187,000 adults live with critical mental health illnesses, and approximately fifty one thousand children live with staid mental health conditions (NAMI, 2010). In 2006, five hundred Alabamians committed suicide caused by unmanaged or under-treated mental illnesses.

Statistics indicate that the state loses one life every fifteen minutes through suicide making suicide the 11th leading cause of demise overall, and the 3rd leading cause of death among young adults and youth aged between fifteen and twenty four years. Between the year 2006 and 2007, 64% of Alabama students aged over fourteen years and living with critical mental health disorders dropped out of high school despite receiving special education services (NAMI, 2010).

The state of Alabama closes most of its state-run psychiatric facilities, an aspect that l creates an increased demand for psychiatric services following deinstitutionalization of mental health patients. Closing down all, but two state mental health facilities leaves the state with few providers of psychiatric services to achieve the increased need for mental health facilities and services. The Department of Mental Health in Alabama stresses that it is crucial to prepare the community for return of patients before patients are released from mental health hospitals.

Deinstitutionalization has instigated the elimination of state mental health hospitals, and has led to ninety percent decrease in facilities and resources needed in psychiatric hospitals. It places a great burden on communities, which do not have the resources and infrastructure to treat people with mental health needs. The state faces resistance to the placement of transitional homes in residential communities because these homes become a nuisance to the community.

However, most communities accept facilities that are well managed, and those with enough resources to cater for the needs of the ex-patients. Background Information Mental health officials from Alabama plans to dismiss nine hundred and forty eight employees and terminate operations of all, but two of the state psychiatric hospitals. One of the hospitals that left operational only handles forensic patients while the other one handles geriatric patients (Plotnik & Kouyoumdjian, 2010).

As a result, mentally ill patients are blocked from accessing psychiatric treatment from these facilities with exception of the elderly or those who commit crimes. Department of Mental Health in Alabama asserts that this move allows the state to extend community care. Ongoing deinstitutionalization has led to a reduction of the state hospital beds by 90% to offer community services and less-restrictive treatment (Plotnik & Kouyoumdjian, 2010). Law enforcement facilities are under serious pressure because of problems linked to untreated mental sickness.

State hospital emergency rooms are full of persons with psychiatric crisis who cannot be accommodated given the scarcity of beds. Alabama community experiences shattering occurrences instigated by rampage killings perpetrated by people with untreated mental illnesses. Deinstitutionalized persons with chronic mental sickness live in the streets, prisons or jails, suffer, and commit suicide. The state is faced with challenges of handling deinstitutionalized persons and new mental health patients coming from the community. Yanos et al. (2001) confirm that there is a critical public health issue for deinstitutionalized people.

About sixty percent of deinstitutionalized people suffer premature deaths courtesy of health conditions such as cardiovascular, infectious and pulmonary diseases that could be managed and treated. Thirty to forty percent of mortality is because of accidents, injuries and suicide. Deinstitutionalized persons suffering from schizophrenia die of cardiovascular diseases promoted by smoking and excessive obesity. According to Yanos et al. (2001), people with critical mental illness lead a marginal life because of stigma, social isolation and fear. From this perspective, deinstitutionalized people are vulnerable to social and health problems.

Deinstitutionalization refers to the release of mental patient from mental hospitals and their return to the community to build up more self-sufficient and fulfilling lives. In 1950, there were 550, 000 patients in mental hospitals in the United States. Following deinstitutionalization, the number of patients in mental hospitals dropped to approximately 150, 000 in 1970, and about 80,000 in 2000 (Yonos et al., 2001). Relocating patients from state-run psychiatric hospitals back to the communities started in 1960s. The establishment of civil rights legislation instigated the movement, and it resulted in enormous relocation of mentally sick persons.

Deinstitutionalizing mentally sick people appeared to be a humane thing, though well intended, this decision has left so many people in far worse situations compared to the ones they persevered while in psychiatric hospitals. Following deinstitutionalization, people face homelessness, poverty, stigma, inadequate treatment and social isolation. As a result, deinstitutionalization has created more problems than benefits for deinstitutionalized persons, and to the entire community. The objective of deinstitutionalization is only partly achievable.

Some ex-mental patients do live in well-run halfway houses, but past studies show that halfway houses remain poorly maintained, employ untrained staff and offer little or no treatment to patients. Major problems include lack of funding and poor supervision of halfway houses. Because of lack of sufficient and good halfway houses, scores of deinstitutionalized patients end up on the streets and they become homeless. Twenty-five to eighty percent of homeless people in the United States have serious mental disorders, and they receive little or no treatment (Plotnik & Kouyoumdjian, 2009).

To offer mental health treatment for the homeless and those released from psychiatric hospitals, community mental health centers facilitate the treatment and care of these people. According to Plotnik & Kouyoumdjian (2010), there is a need to offer treatment to the homeless, county prisoners and deinstitutionalized individuals. One way to provide professional assistance to help these people is through the establishment of wellness and recovery centers. Deinstitutionalized patients ascertain that while most of them are being upheld on medication, very few are having their medication cautiously monitored (Weisbrod & Komesar, 1978).

In numerous cases, family members pick up a prescription renewal and scores of patients are maintained in the community not because of the mental health services that they receive, but because of the dedication of friends and family members. The constant deinstitutionalization of patients in the state calls for adequate facilities to offer in-home and on-site care for adults. Basic deficiencies in the provision of mental health services are because of lack of proper facilities, resources, leadership skills and organizations of mental health services in the state.

Purpose of the Project Deinstitutionalization has instigated scores of problems among them homelessness, suicide, social isolation, stigma and under-treatment. Deinstitutionalization paves way for introduction and development of community mental health facilities. This process allow nurse practitioners to set up their own practice aimed at helping deinstitutionalized patients through addressing the issues linked to deinstitutionalization. To achieve this goal, nurse practitioners must hold excellent leadership skills to allow them establish and use the available resources for the benefits of their clients. Nurse practitioners must be able to introduce innovative change.

Leadership in nursing is a vision, expectation and goal, and facilitates change that is measurable and lasting. A good nurse leader is a visionary and the catalyst that brings power to the nursing practice, and creates an atmosphere in which innovation regarding nursing practice can flourish. With enough drive, determination and energy, a nurse practitioner can set up his/her own business. The overall aim of this project is to investigate the effects of deinstitutionalization besides exploring how Nurse Practitioners can own and operate a business.

The project proposes establishment of a Psych/MH Nurse Practitioner Led Wellness and Recovery Center in Bessemer, Alabama that will be designed to help deinstitutionalized Individuals. Significance of the Study Coincidence of deinstitutionalization and homelessness, stigma, social isolation and untreated health conditions is indisputable. This empirical study, which seeks to establish a nurse practitioner-led wellness and recovery center benefit the community, deinstitutionalized individuals and the nurse practitioners. Establishing a wellness and recovery Centre in Alabama helps in addressing the increasing number of patients released from state-run psychiatric hospitals.

Wellness and recovery center enhances the living conditions, treatments, social life of mentally ill persons besides relieving the burden of care for the community and families. Patients get enough resources to address their behavioral health needs, and the demand for mental health services become achievable.

The project functions as a revelation to nurse practitioners wishing to set up their own practice, and it facilitates constant improvement of behavioral health care services that is offered to the community through the creation of an atmosphere that strives to achieve the distinctive healthcare requirements of deinstitutionalized persons. Patients have the prospect to access the facility and receive their mental health needs at reduced costs.

Through excellent leadership, the facility helps deinstitutionalized persons adjust to community life through providing services that achieve their disease prevention needs, health promotion and community health assessment besides providing a good option to institutionalization. The Nature of the Project This research entails a systematic exploration to get answers to the problem of deinstitutionalization, and the way a nurse practitioner can address this problem through establishing a wellness and recovery center for the deinstitutionalized people. Deinstitutionalization instigates the problem of homelessness, stigma, social isolation, suicide, poverty and inadequate treatment.

Alabama State's strategy of releasing people to the community and closing all its psychiatric hospitals overwhelms the community. To help solve the problem of deinstitutionalization, nurse practitioners can establish a wellness and recovery center to address the needs of the mental health patients released from the state-run mental hospitals. To ascertain how the problem of deinstitutionalization can be addressed, and the resources and facilities required to set up a wellness and recovery center, data must be collected from the affected person through an explanatory or descriptive analysis.

This project entails an empirical inquiry founded on measured and observed phenomena within the context of real-life situation, and derives knowledge from real experience as opposed to a belief or theory. The research methodology will be determined through the research questions.

Given the research question that tries to ascertain the link between deinstitutionalization and other factors such homelessness, stigma, under-treatment to mention but a few, and the role of a nurse practitioner in curbing the effects of deinstitutionalization, the project takes a case study approach with both qualitative and quantitative analysis. Quantitative research focuses on origin plans, and it findings are readily interpreted and analysed. Qualitative research is more responsive and open to its participants.

This project focuses on small groups of people to create a conceptual framework that entails the final deductions. Large samples must be used to derive the results. A case study is involved given that the research is more qualitative than quantitative. First-hand data is collected through interviews, observations, and questionnaires distributed to the study sample. This calls for integration of both qualitative and quantitative approaches. Quantitative approach ensures precision through reliable instruments, control of samples through design and sampling.

However, quantitative research does not allow for control of variables given the complexity of human experience. Quantitative research can also fail to consider the distinctive ability of people to construct their own understanding and interpret their experiences. Given the subjective temperament of qualitative data, and its single context origin, the approach faces validity and reliability issues. Based on the weaknesses and strengths of both qualitative and case study approach, triangulation significantly aids in dropping the shortfalls of a single research perspective in this manner augmenting the aptitude to interpret results.

Triangulation guarantees the validity and reliability of the research through cutting back the flaws of the perspectives involved. Triangulation refers to the means through which validity of research findings is ensured by employing different research perspectives. This approach helps in overcoming the biases and weakness that arises from the employment of a single research method. As a result, the research makes use of qualitative, case study data collection methods while interviews, observation, and questionnaires are used to assess the effects of deinstitutionalization.

From this perspective, the project adopts a methodological triangulation, which entails application of qualitative methods to ensure results validity. While this approach is time consuming due to greater planning and resources involved, it augments the research confidence, provide apparent comprehension of the problem, discover distinctive findings and comprehension of the phenomenon being studied. Research Questions 1. What is the relationship between deinstitutionalization and homelessness, social isolation, inadequate treatment, suicide and stigma? 2.

How can Psych/MH Nurse Practitioners help in addressing the problem of deinstitutionalization? Theoretical Framework Theoretical framework guides a research project, identify the variables to be measured, and it involves a collection of integrated ideas. Deinstitutionalization displays a major challenge to the policy of mental health.

A shift in psychiatric bed capacity and closure of all but two psychiatric hospitals ran by the Alabama state may lead to other effects such as an increase in the rate of suicides, social isolation, poverty, stigma, diseases such as Pulmonary diseases, cardiovascular diseases, and homelessness. Deinstitutionalization minimizes chances of receiving adequate treatment because the remaining psychiatric hospitals only take in people with serious mental health problems who are deemed to be a threat to the society. Deinstitutionalization may increase drug abuse that consequently instigates suicide.

People relocated from mental health facilitates may face stigma and social isolation when the community is not ready to accept them. As a result, these individuals become homeless and live in the street where they die or commit suicide due to lack of adequate care and basic needs. Deinstitutionalized people living in the streets become vulnerable to infectious diseases such as TB because of poor living conditions.

Although deinstitutionalization is a humane act that functions to reduce overcrowding in psychiatric hospitals and in favor of expanding community care, the action comes with enormous negative upshots to the community and patients. Focusing on the Health Belief Model which is a psychological framework that tries to predict and explain behaviors, deinstitutionalization will change the beliefs, attitudes and behaviors mental patients and those surrounding them (Mutsatsa, 2011).

Following deinstitutionalization, a nurse practitioner in the field of mental health can help prevent the problems linked to deinstitutionalization through establishing a wellness and recovery center to cater for the health and social needs of deinstitutionalized persons (Mutsatsa, 2011). Through establishing a wellness and recovery facility, the nurse practitioner prevents the negative health conditions and help mental health patients to take a recommended action to protect their health and lives.

While state-run psychiatric hospital serves a safe area for people with severe mental illnesses, it is apparent that the closure and reduction in beds capacity in the two psychiatric hospitals that remains operational following the ongoing deinstitutionalization, leads to a rise in rate of suicides, stigma, social isolation, homelessness among other major upshots. Deinstitutionalization supports establishment of community-based mental health centers that lowers the call for prolonged hospitalization. Establishment of community-based mental health facilities helps in preventing the negative aspects linked to deinstitutionalization.

Nurse practitioners in the mental health field believe that deinstitutionalized people face negative aspects once they are released to the community. The nurse practitioners and social workers believe that the negative consequences of deinstitutionalization are avoidable making them also believe that establishing a wellness and recovery center protects deinstitutionalized persons from homelessness, suicide, health issues among other social issues. Taken together, nurse practitioner understands the barriers to provision of better mental health care and services with respect to funds and requirements for establishing a community-based wellness and recovery center.

However, these barriers can be addressed through marketing strategies and seeking funds from the government, investors, loans and well-wishers (Horrocks, Anderson & Salisbury, 2002). This way, the project can attain its utility from the well-being of patients and thereby enhance the general access to mental health care for deinstitutionalized people (See Figure 1). Figure One: Conceptual Framework Model The effect of deinstitutionalization relies on availability and accessibility of resources for community-based mental health facilities.

A central element in prevention of negative effects of deinstitutionalization includes management of mental health issues through appropriate channels that includes placement of deinstitutionalized people to wellness and recovery centers. This implies that deinstitutionalization instigates negative upshots to the patient, but these effects can be prevented through well-established facility to ensure wellness and recovery of the deinstitutionalized persons.

Definition of Key Terms Triangulation: means through which a researcher ensures the validity of research findings through employing different research perspectives Deinstitutionalization: Release of mental patient from mental hospitals and their return to the community to build up more self-sufficient and fulfilling lives Scope and Limitations This paper focuses on specific aspects that affect deinstitutionalized persons and aspect that helps in addressing the problem faced by deinstitutionalized individuals.

The focus is on how establishing a wellness and recovery center benefits mental health patients who are released from the state-run psychiatric hospitals and those coming from the community system. The issues of suicide, homelessness, stigma, poverty, inadequate treatment and social isolation are subject to assessment. The research takes a case study approach with qualitative analysis where both open-ended questionnaires and interviews are used for collection of primary data. A pilot study is conducted prior to the actual research.

A pilot study is important as it evaluates the practicability of a research besides enhancing the research design. Pilot is conducted on a smaller sample of the larger population in a research. Study limitations identify confronts that researchers faces in the course of performing a research study. One of these limitations includes respondents giving socially acceptable answers, but irrelevant answers to avoid upsetting the researcher (Kombo and Tromp, 2006). To avoid such answers, the researcher assures the respondents utmost confidentiality.

Secondly, the assortment of impediments that may hinder some participants from providing their correct responses may affect the research findings. This could result into responses that are low in validity and reliability. To avoid this, the researcher must evaluate the questions to make sure they are clear and specific and after the research analyzes each answer to see if it is giving the appropriate information. Moreover, the research must select pertinent study sample.

Given that the research involves a small number out of a larger sample, the findings may not be generalized. Other limitations that affect the planned project of establishing a wellness and recovery center to assist deinstitutionalization include human resources limitations, time and financial constraints. Summary Deinstitutionalization is a permanent trend where fewer persons with mental health issues live in mental hospitals. The trend allows transfers of mental health patients to community-founded mental health facilities (Bachman, 1996).

Deinstitutionalization demonstrates evolution in practice, structure, purposes and experiences of mental health care, and it is a liberating, human strategy option to restrictive care and attributes to lowered demand for hospital care. While deinstitutionalization represent shift in the extent of mental health care from prolonged, custodial in-patient care to shortened outpatient care, the procedure of deinstitutionalization merged with scarcity of community-founded care leads to visible homelessness problems, social isolation, stigma, inadequate treatment, suicide and other opportunistic diseases such as TB.

Between thirty and fifty percent of homeless persons in the United States of America are persons with mental health issues. Mental health patients confined to mental health institutions adapt their social conduct to the conditions of the institutions (Newman, Turnbull & Berman, 2010). Persons who have been confined in hospitals or other long-standing care facilities find changing to community life overwhelming and upsetting. In this regard, adjusting to outside life following deinstitutionalization becomes difficult and this calls for intervention from Psych/MH Nurse Practitioners, social workers and the community.

Chapter 2: Literature Review Introduction Literature review refers to close examination and description of previous research studies relevant to a given topic or field. This section reviews existing literature from other scholars on the role of Psych/MH Nurse Practitioners in addressing mental health problems, consequences of a release from psychiatric hospitals, and integration into the community system. Chapter 2 offers an overview of the inquiry field entailing what scholars, professionals and researchers say regarding deinstitutionalization, the role of Psych/MH Nurse Practitioner, PN as business owners and PN-managed care centers.

History and the Role of Mental Health NP Psychiatric Mental Health field of nursing was the pioneer specialty-nursing group to emerge within graduate education context. These clinical nurse professionals in psychiatric mental health nursing materialized towards the end of 1950s. Psychiatric Mental Health NPs were set as nurse therapists who could evaluate mental health problems besides providing group, family and individualized therapy.

A prototype shift in comprehending psychiatric and mental health disorders instigated introduction of neurobiological foundation of these situations, and has changed the practice atmosphere and promoted the development and need for Psychiatric Mental Health NP. Psychiatric Mental Health NPs are presently in high demand, and they use both conventional therapeutic methods and novel pharmacological interventions to control mental health issues of their clients.

Psychiatric Mental Health Nursing has its roots in the 19th century following the reform movements in order to reorganize mental asylums into hospital settings and create care and treatment for the mentally ill. Initially, the organized effort to develop psychiatric nursing started at McLean Asylum in Massachusetts in 1882. Some of the critical leaders in the development of this specialty include Harriet Bailey, Euphemia Jane Taylor, and Lillian Wald who participated through their support to the Mental Hygiene Movement.

In 1913, the first nurse-organized training program for psychiatric nursing within a general nursing education program was established in the context of Phipps Clinic at John Hopkins Hospital. Nursing leadership was essential in the development of psychiatric mental health nursing from the narrow focus of medical models and mind-body dichotomy towards a bio-psychosocial approach in addressing mental illness thus the inclusion of the concept of mind as expressed in behavior and adaption experience.

Adelaide Nutting, a well-known nursing educator at Teachers College at Colombia, focused on the expression of the role or influence of nursing in the promotion of recovery from mental illness and prevention of the mental illness through the educative elements of nursing care. Psychiatric mental health nursing leaders were essential in identifying and developing relevant, specialized bodies of knowledge, and securing the didactic and clinical experiences vital for the students to achieve competence as mental health nurses.

Success has been evident in the promotion of integrated mental health concepts into general nursing educational programs initiating and facilitating national public awareness of the correlation of mental and physical health towards the achievement of the patient outcomes. Psychiatric mental health nursing practice moved beyond the walls of state hospital institutions in meeting mental health needs of the holistic community through the efforts of the pioneer leaders within the context of this specialty.

Position and visibility of the specialty became crucial in relation to the next wave of reform in the 1940s following the passage of the Mental Health Act. In the late 1950s, specialty nursing at the graduate level began to evolve in response to the passage of the National Mental Health Act of 1946 as well as the creation of the National Institute of Mental Health in 1949.

The act was vital in identifying psychiatric nursing as one of the four core disciplines for the provision of care and treatment for the mentally ill in conjunction with social work, psychology, and psychiatry. Nurses were essential agents in the provision of treatment in addressing the growing demand for psychiatric services resulting from increasing awareness of post-war mental health issues. Psychiatric nurses played an important role in the development of the advanced practice-nursing role thus the establishment of the specialty certification in relation to the American Nurses Association.

Currently, specialists in relation to Psychiatric Mental Health Clinical Nurse and Practitioners adopt and integrate titles reflecting the language in state practice acts and regulations. These entities share similar core competencies in relation to the clinical and professional practice. The Role of Nurse Practitioners According to Buppert (2009), nurse practitioners are registered nurses with one or two years of additional education which prepares them to offer many of the same services that doctors provide.

Nurse practitioners work with other health care professionals such as doctors, counselors, therapists and nurses, and they offer health and wellness care to people of all ages. Nurse practitioners are lawfully allowed to diagnose, order X-rays, laboratory services and prescribe medications, and they are prepared through advanced education and clinical training to offer a wide range of acute and preventative health care services to persons of all ages (Buppert, 2009).

Most NPs hold master degrees while others hold doctorates degrees, and they are certified to work in different areas among them mental health/psychiatric care. Before the emergence of advanced nurse practice nurses, the legal practice scope of nurses excluded treatment and diagnosis. Nurses performed physicians' orders and in 1970s, some state nurse practice Acts received modifications to include nursing diagnoses in the nursing practice scope (Buppert, 2009).

Following the shortage of physicians that rose in 1960s, it became evident that the restraints on the nurses to make medical diagnoses, and the shortage of physicians limited access of health care for persons in medically underserved areas consequently making some nurses to join forces to form what is now known as the nurse practitioner. Nurse practitioners are primary care providers who practice in acute, ambulatory and long-term care settings. With respect to other practice specialty, nurse practitioners can offer medical and nursing services to groups, families and individuals.

Nurse practitioners can be employed or start their own private practice following the requirements stipulated by their state laws. To practice as an employee or in private practice in Alabama, a nurse practitioner must hold an RN license, graduation from an organized program and clinical experience that extends basic educational preparation, must hold a masters degree in nursing and get certification from a national certifying agency recognized through the Board of Nursing. The favorable regulatory setting offers nurse practitioners with the prospect of opening their own private practices.

Psychiatric/Mental Heath NP offers a wide assortment of health care to children, adolescents and adults in primary care settings, psychiatric emergency services, outpatient mental health services, community health centers, psychiatric hospitals or in private practice (Knudtson, 2000). Psychiatric and mental health NPs are licensed to offer physical assessment, emergency mental health services, physical and psychosocial assessments, diagnosis, treatment plans and they can manage the care of patients (Knudtson, 2000). Psychiatric/Mental Health NPs also functions as consultants and as a result, they can practice independently in different settings.

Deinstitutionalization Deinstitutionalization depicts a most widespread shift in mental health strategy. This procedure has instigated the enormous transfer of critically mentally sick individuals from psychiatric institutional care to the community with the aim of favoring community treatment. Structural shifts in the community mental health system are a major factor of deinstitutionalization. These changes concern policy makers and mental health professionals given that the reducing capacity of state-run psychiatric facilities may put at risk the care of the destitute and critically ill mental patients (Bachman, 1996).

Reducing the number of psychiatric facilities would be effective if the need for these facilities also reduces. On the contrary, the demand for these facilities and mental health services is still high and calls for privatization of in-patient psychiatric market where Psych/MH Nurse Practitioner can own and operate their own private practice. According to Salokangas et al. (2002), the death rates caused through suicides among patients with mental health illnesses, specifically schizophrenia, augmented following deinstitutionalization and reduction of beds in psychiatric hospitals. Obsy et al.

(2002) confirmed that in Denmark, a substantial negative link is noted amid reduction in public psychiatric facilities and suicide rates. Results from previous study carried out by Hansen & Arnesen (2001) confirmed a rise in homelessness, suicide rates, and social isolation following reduction of psychiatric facilities.

In the U.S., Haugland and associates assessed the death rates of one thousand and thirty three deinstitutionalized persons, and following a three and a half year follow-up time; these patients were eight times likely to commit suicide, become homeless following stigma and social isolation or die of accidents compared to people without mental health issues (Haugland, Craig, & Goodman 1983).

In contrast to the these findings McGrew et al.(1999) reported improvements in life quality and operation amid deinstitutionalized persons treated through private mental health facilities following closure of psychiatric facilities run by state. According to Yoon & Bruckner (2009), deinstitutionalization process in the state of Alabama has been executed without adequate assessment of possible health dangers to patients, and the situation can only be solved through privatization of the mental health market. According to Bachman (1996), privatization of mental health services affects multiple goals.

This process assists states in attaining economic, organizational and political objectives thereby avoiding interest groups' influence besides leveraging state facilities. Privatization of mental health services allows mental health patients to get services and treatment of community-based providers. Nurse Practitioners as Business Owners According to Brown (2006), nurse practitioners need to comprehend their scope of practice, the confronts they may face in offering care to patients, the kinds of job prospects available, advanced practice nursing roles and how these roles complement each other, and certification needs to establish their career goals.

Nurse practitioners make a crucial contribution to the increasing access to county, state, national and community health care services in secondary, tertiary and primary care settings. The focus of NPs role has been to provide direct care using a family-centered, holistic perspective to the undeserved, unserved and impecunious clients. NPs care achieves equal or better upshots compared with upshots that physician provider.

Nurse practitioners work independently in scores of primary care settings and collaboratively in hospital, outpatient and in-patient settings and they create collegial links with physical therapists, physician, pharmacists and other health care professionals. Brown (2006) confirms that nurse practitioners are building up businesses and become well informed in owning and administering companies. Nurse Practitioners are advocating for access to care and they are becoming politically astute in influencing client-focused public policy, promote NP prescriptive power and eases credentialing obstacles in practice (Knudtson, 2000).

When making an informed decision concerning owning a business NPs evaluate their career trajectory, determine the level of financial resources needed, examine career options and assess their retirement goals. Once an NP determines that his/her best choice is to establish a new business, numerous steps must be taken to build up a successful business that upholds financial sustainability (Knudtson, 2000). These steps include business planning that calls for analysis and research. This process entails collecting data, consultation with business associates and networking in the community.

Nurse practitioners are in distinctive stance to evaluate, assess and develop independent business prospects and partnership given that they hold special knowledge and skills in nursing and hold insights in emerging and current consumer needs. For instance, deinstitutionalization creates prospects for psychiatric-mental health nurse practitioners to establish wellness and recovery centers for the deinstitutionalized people. Nurse Practitioners wishing to set up their own business must conduct surveillance of health care and business settings to develop awareness of client's needs, desires and wants.

This process offers prospects for Nurse Practitioners seeking to fill the consumer service or product void that exists through entrepreneur and intrapreneur ventures. Determining business prospects that represent prospective potential growth or shifting health care practices promotes financial viability of the operation of the business. Nurse practitioners seeking to set up their own practices must assess the community resources available for setting the business, which will allow them to link with significant stakeholders.

Besides, assessing availability of resources, NPs must create practical business plans that help in assessing the market forces and financial feasibility of the proposed business venture. Business plan maps out the business proposal in a coherent and organized manner and it guides the overall business operation and expenditure. NPs must seek accounting or legal help after having an idea of the kind of business they want to initiate.

Business plans should contain strategic planning that determines the accomplishment of the proposed business and how the resources will be utilized to achieve the business plan. Nurse Practitioners must conduct market analysis that maps out the potential market share for the products and services provided. Nurse-practitioners-led care centers have been in existence since 1965 and they offer a distinctive perspective to primary care (Brown, 2006). These care centers served disadvantaged populations, and they limit the financial stability of the patients.

To set up a successful care center, adequate business planning, availability of revenue sources, prescriptive authority is paramount. These care centers focus on providing holistic, client-centered care to families, individuals and communities. According to Brown (2006), the first step to establishing a NP-led center in a community requires using innovative perspectives and creativity in shaping one's practice besides determining the model of care. Market analysis is paramount as it helps in assessing the clients and their needs.

Sound business practices and adequate resources that include physical facilities with code regulations and licensure are paramount because the achieved profit margin helps business owners in offering their clients with valuable services. NPs can attain grant from local organizations, loans from banks or investors to set up their own practice besides adequate staffing to ensure better management of patients (Brown, 2006). Nurse practitioner-led practice must be credentialed, and NPs must develop community partnerships to ensure a smooth learning of the care center.

Conclusion Deinstitutionalization holds adverse effects to the deinstitutionalized patients and the community as whole. Deinstitutionalized patients receive inadequate treatment, become homeless and they die out of suicide or other unmanaged illness. Information attained from previous literature indicates that Nurse Practitioners can own their own businesses aimed at expanding care to the disadvantaged populations. This way, Psychiatric/Mental Health NPs can help the society address the negative effects of deinstitutionalizations through establishing a NP-led wellness and recovery center for deinstitutionalized people.

Summary Chapter 2 focused on the illustration of the History and the Role of Mental Health NP with the aim of offering critical understanding of the development of the specialty from the 19th century to the current state. Another element of the literature review section was the examination of the role of the nurse practitioners in relation to the context of the specialty.

Nurse practitioners play critical roles in the development of the specialty thus the need to understand and incorporate their roles and obligations in researching about the Mental Health NP. The third aspect of the literature review was the aspect of deinstitutionalization with reference to the concept of Mental Health NP. Finally, chapter one also focused on the evaluation of the nurse practitioners as business owners in the case of Mental Health NPs in Alabama.

This sets the ground for the development of effective and efficient methodology in relation to the third chapter of the dissertation. Chapter Three: Methodology Introduction The research methodology is a structured procedure of carrying out a research (Tashakorri & Teddlie, 2010). This chapter details the actions, progress, process and the success of the proposed research. A methodology section explains and discusses the instruments, project design, sampling technique, data collection and data analysis techniques employed by the researcher in efforts of solving the research problem.

Appropriateness and practicability of the methods used, validity of the research design as well as the appropriateness of the project in solving the research problem forms part of this chapter. Project Proposal Proposed Wellness and Recovery Center will be a Limited Liability Company registered in the state of Alabama, and will be positioned in Bessemer, Alabama. This proposal assesses the project and helps the potential management in planning and anticipating capital disbursement priorities. The proposal holds four phases, which include panning, financing, implementation and monitoring.

Given the huge amount of capital needed to set the wellness and recovery center for the deinstitutionalized persons, funds will be sourced from Loans and investors. The total capital needed amount to 750, 000 dollars. These funds will be used to cater for start-up expenses highlighted in the Table below.

Figure 1: Proposed Cost Summary and Funding Sources The proposed project financial projections for the coming three years are presented in Figure 2 Figure 3: Cash Flow Financial Projection Products and Services The wellness and recovery center is expected to begin its operations in Bessemer, Alabama in 2014. Given the ongoing deinstitutionalization in Alabama, the establishment will offer its services to persons with behavioral health requirements through providing in-patients and on-site patient care. At the start, the organization will treat 12 residential patients.

The organization will provide professional, conscientious and compassionate care to adults with behavioral health needs from 6 am to six pm. Other services to be provided in wellness and recovery center include: Counseling and assistance with the transition to community life Maintenance of physical health and well-being Psychiatric assessments Medication management and follow-up care Employees and Market Analysis The organization will seek the services of a nurse practitioner, two nurse technicians and a social worker. These employees will guarantee physical, mental and emotional well-being of deinstitutionalized persons.

Horizon wellness and recovery center will be located in Bessemer, Alabama in the most highly populated counties in the Alabama holding 680,000 persons. The organization will serve a populace within a 50-mile radius of Bessemer. The following Chart offers an overview of the company's target market. Figure 4: Target Market According to the chart, about 26% of the major market segmentation in 2011 is under the Medicaid Program. About 25% are individuals will private insurance or coverage while 18% represents other states and local entities.

Other sections of the market segmentation include 11% of the Medicare program, 13% for out-of-pocket payers, 4% of other private payers, and 3% on other federal entities. Market Needs Alabama State is currently closed all but two of its state-run mental hospitals. The two mental facilities that will remain operational will include forensic psychiatric hospital that will be limited to mentally ill persons who have committed crimes, and a geriatric psychiatric hospital.

Treatment Advocacy Center, a national nonprofit dedicated to eradicating barriers to the treatment of mental illness asserts that the next several years will see almost all patients under state care in Alabama under duress released into the community. This change calls for the need of a treatment center that will assist in provision of constant behavioral care to numerous adults who will no longer rely on state-run mental health institutions.

Industry Analysis Proposed wellness and recovery center will function in the 9.5 billion dollars Mental Health and Substance Abuse Centers in the U.S. industry. This industry is developing in rejoinder to the increasing awareness regarding mental illness, and the ongoing deinstitutionalization in Alabama will probably boost demand for mental health services in Alabama. Competition Given the increased influx of persons with behavioral health needs instigated by the ongoing deinstitutionalization, the demand for mental health services exceeds the supply, hence there will be little or no competition.

However, there are several mental health centers such Bondurant Teresa, Birmingham VAMC Bessemer Clinic, Bessemer Group Home2 and Mental Health Management in Alabama, which only accommodate a few patients. Strategy and Implementation The proposed wellness and recovery center will create a brand that will demonstrate its devotion to offering aftercare treatment for deinstitutionalized persons. The organizations promote adoption of its professional mental health services via different methods of advertising. A logo that will appear on all marketing resources will facilitate extension of brand awareness.

Innovative and excellent marketing strategies will enhance brand recognition besides sending apparent messages concerning the merits of the services offered by the organization. Billboard advertising, positive word of mouth and direct mails and clear links with hospitals will be used to market the services and products of the proposed organization. Positive marketing strategies will be used to facilitate commencement of operations in 2014, establishment of a trusted name in after-care treatment of deinstitutionalized persons, establishment of an extensive market share and in generation of sufficient revenue to allow expansion of operations.

Management and Monitoring Owner of the proposed center is a skilled nursing professional with twenty- five years experience in management and administration, behavioral health and program development. This professional nurse has worked in residential treatment setting for the Alabama Department of Mental Health and Mental Retardation, and has worked for 18 months in a residential treatment unit with the Alabama Department of Corrections.

Owner is a Board Certified Advanced Practice Registered Nurse currently completing a doctorate program in Executive Nurse Leadership, and by the date of the Company's opening, she will be board certified as a residential treatment provider for individuals with importunate mental illness and/or developmental delays. The owner holds extensive experience in working with persons behavioral health needs, and together with her formal training and a deep and enduring commitment to her field, she will make an idyllic executive for the proposed wellness and recovery center.

Methodology Introduction Research methodology refers to the nature of the research section from the first chapter with the aim of stating and justifying the rationale in relation to the use of a specific paradigm or theory. Research methodology and design are derived from the problems under discussion, theoretical framework of the project, and the purpose of the study. Research methodology and design are critical in description of sufficient details in order to solve the problems while answering the research questions.

Research methodology and design must be appropriate and justified in relation to the hypotheses or desired outcomes. Chapter 3 will focus on the clear delineation and explication of the type of methods applied in addressing the research questions and problems. The chapter will focus on the elaboration of the effective and efficient methodology towards the achievement of the desired outcomes through integration of six critical sub-headings. These will include project design, instruments, data collection, management, and analysis plan, validity, methodology appropriateness, and feasibility appropriateness.

The final sections of the third chapter will focus on the conclusion and summary of the major components of the research methodology towards the achievement of the desired outcome. Project Design This research assumes a qualitative research method and case study design. This perspective facilitates collection of first hand data concerning the effects of deinstitutionalization, whether the adverse effects of deinstitutionalization can be solved though establishment of a wellness and recovery center and NPs perception of the value of establishing a wellness and recovery center.

Based on the strengths and biases of both qualitative and case study research, data and methodological triangulation lowers the deficit of a single perspective through raising the ability to interpret the findings (Munhall, 2011). Triangulation guarantees the validity of results by putting to remission flaws of qualitative and case study research perspectives. Population and Sample This research engages a sample of 15 respondents. The 15 respondents will participate in the case study with the aim of achieving the goals and objectives of the research questions.

The exploration time will be about 14 months (June 2012 to August 2013). The respondents compromise of Psychiatric/Mental Health Practitioners. Respondents are drawn from Bessemer in the state of Alabama. The participants age twenty-one years and above. Study sample is selected through purposive sampling. Participants are chosen based on the understanding of the population and the objective of the project. Subjects are to be chosen based on some characteristics.

Nurse practitioners involved in the project must be those specialized in mental health and have met all the state requirements for practicing as NPs. Data Collection Instruments Data collection procedures entail the use of interviews and highly structured questionnaires for collection of primary data. A systematic review of literature regarding deinstitutionalization and Nurse Practitioners as business owners assisted in collection of secondary data. To asses NPs perception of the value of establishing a wellness and recovery center, the researcher developed and administered NPs perception survey.

Survey questions were founded on theoretically derived constructs, which include perceptions of innovation and business ownership, and critical success factors linked to NP-led business. Interviews give the researcher the prospect to gather primary data, which can be checked for clarity, and which can be used for future references especially when audio-taped interviews are entailed.

In the Interview method, the researcher turns to be a key element in the study, as he is required to become a learner who gets the participants to characterize their practices in their own words, and according to how they understand them best. Interviews provide the researcher with a prospect to explore deeper into respondent's reactions thereby guaranteeing an increased rate of relevant responses.

In-depth Interviews are conducted on Psychiatric Nurse Practitioners, as they allow the respondents to express their views regarding the problem faced by mental health patients after their release from psychiatric institutions besides assessing NPs perception of the value of establishing a wellness and recovery center (Munhall, 2011). This is an illustration of the need to integrate descriptive method in answering research questions and objectives. Structured interviews will be 60-90 minutes in office of PMHNP.

Highly structured questionnaires are administered to Psychiatric Nurse Practitioners, and they ensure provision of relevant information from the respondents. Structured-questionnaires limit the responses of the participants hence providing only pertinent information. Contrary to open ended-questionnaires, assessing findings from structured questionnaires is easier and takes less energy and less time. Ethical and Legal Considerations Prior to the start of a collection of data from the participants, the researcher must practically set the study in a manner that the project achieves ethical adequacy.

Maintenance of dignity and privacy as well as respondents welfare protection are paramount. Physical and emotional well-being of the respondents must be addressed, and it compels the researchers in adhering to procedures that do not exploit the subjects, but stick to procedures that safeguards the physical, psychological and emotional well being of the participants. Consent forms must be provided, and the participants allowed to sign them after understanding the nature and objective of the research.

The main objective of IRB is to ensure the protection, safety, and welfare of human subjects in relation to the execution of the research exercise. Critical steps and processes are essential for the achievement of the goals and objectives of IRB in the collection and analysis of data. The first process of IRB is essential training for the researcher or investigator with reference to the required human subjects before submission to the IRB.

In addition, there is a need for continuity in training in the form of at least one-hour annual training and additional CITI module and VHRPP workshops for the protection of the human subjects. Timing is an essential component of the IRB process thus the need to start planning for the achievement of effective and efficient outcome of the research process. There is need to acquire sufficient time for the needs and requirements of the research as well as IRB review that depend on the complexity of the study.

Another critical element is the prompt response to the correspondence from the IRB Committee with the aim of ensuring effective travelling plans. There is a need to focus on extensive consultation from other colleagues that have submitted to the IRB with the aim of enhancing the effect of the research questions. Finally, it is essential to develop a simple and concrete research proposal in order to address the needs and demands of the research questions, hypothesis, and objectives.

Data Analysis Data analysis entails the processes in which researchers, clean, scrutinize, form and transform the collected data in efforts of underlining the most helpful information. Analysis of data facilitates research concludes, implications besides promoting decision-making. Analysis of data is the most multifaceted and enigmatic of all the stages of a given research (Polit & Beck, 2009). Irrelevant data is eliminated and ambiguous questions interpreted. Data is stored electronically and in print form. Key findings on the effects of deinstitutionalization and how these adverse effects must be addressed must be summarized.

The interviews are analyzed through content analysis approach to facilitate identification and explication of major themes. Coded items are scored on a five point Likert Scale from: strongly agrees (5) to strongly disagree (1). This way, a summary report identifying major themes and associations between them is developed. Specific covariance assessment is carried out to identify the effects deinstitutionalization and structured intervention on every upshot variable. In relation to the context of NP1, about 5 NPs took part in the collection process.

about of 4 of the 5 were positive in the case of practicing for 1 to 5 years while one opposed the concept. In the context of the second NP evaluation, all participants were in favor for the practicing between 5 to 10 years. This tendency was similar to the case of the NP3 where all the five participants agreed to the effective and efficient practiving in the specialty for more than 10 years. this is an indication of 100% positive for the two segments in the development of adequate evidence for the research questions.

Validity Validity entails the extent to which measurement accomplishes their expected purpose, and correct inferences made from the research findings. Research design employed herein achieves its intended purpose. A qualitative case study approach ascertains the adverse effects of deinstitutionalization and what can be done to address these effects. A case study is an in-depth investigation of a given issue in real-life context, and it does not rely on available statistics, but on detailed evaluation of a given phenomenon.

A case study research ensures detailed contextual evaluation of restrained conditions and the link shared by these conditions. A case study provides in-depth data as well as close details regarding research topic given that data gathered through this perspective is derived from experiences and practices of people. Data and methodological triangulation help in reducing potential biases within the study process and data analysis thereby ensuring validity of results.

The typical course of action in evaluating the content validity of a measure is to use professionals or experts in the field of mental health (Polit & Beck, 2009). This research requires the researcher to check with experienced research supervisors in the mental health field to assist in improving the design to ensure valid results. During the pilot study, the researcher identifies those items that are characterized by difficulty and ambiguity. Items found to be extremely difficult to the administrator calls for modification.

Pre-testing also necessitates addition of extra items and reduction of others to improve the quality of instruments. The respondents who take part in the pilot testing are not included in the main study. Research assistants go through a training session so that the researcher may come up with a standardized data collection procedure to avoid threats to internal validity. To ensure external validity, the researcher uses variables that are similar to those factors existing in the larger population being studied.

The sample involved is representative of the entire population to avoid threats of external validity. Methodology Appropriateness Given the research question that tries to ascertain the link between deinstitutionalization and variables which include homelessness, stigma, under-treatment to mention but a few, and the role of a nurse practitioner in curbing the effects of deinstitutionalization, a qualitative case study approach offers valid results. Data and methodological triangulation reduce the biases in both qualitative and quantitative data collection and data analysis methods.

Moreover, the research questions provided in the study cannot be answered through single methods. In this regard, an empirical study involving mixed methods is appropriate for this study. Questionnaires, interviews and systematic review of literature offer findings that represent a true reflection of whatever is being studied. Feasibility and Appropriateness The proposed project calls for adequate resources, which include physical facilities, finances and human resources.

The project requires Psychiatric Nurse practitioners who will foresee the running of the business, social works and nurse technicians who will make smooth the process of patient management. Community or state will provide physical facilities while finances can be gotten from investors or bank loans. Availability of these resources will make the project feasible and appropriate. Summary This chapter has analyzed the major steps required to ascertain the problems facing deinstitutionalized persons and the strategy applicable to address these problems.

Research design, sample and sample selection procedure, data collection instruments, which include questionnaires and interviews, data analysis procedure, validity tests, appropriateness of the methods use and practicability of the project, have formed part of this chapter. Methodology chapter entails gathering the required information, analyzing it to achieve the expected results. This section plays a crucial role in the entire research project since the findings determine the practicability of the whole project. Chapter Four: Findings Introduction This chapter presents the findings from the study.

This project ascertains whether deinstitutionalization increases homelessness, stigma, suicide, inadequate treatment and social isolation. To confirm the effects of deinstitutionalization and the value of an NP-led wellness and recovery center, a phenomenological case study approach was employed. Interviews, available literature on deinstitutionalization and NPs as business owners, and structured questionnaires were used to collect data with the aim of highlighting the effects of deinstitutionalization, and how Psychiatric Nurse practitioners can address these effects through setting up a community mental health center. Participants for the research include Psychiatric Nurse Practitioners.

Study respondents include American males and females aged between 33 and 65 years. Respondents include Nurse Practitioners, both male and female nurse, certified and have practiced in the field of mental health for at least five years. Data Analysis Findings indicate that most of mentally ill out of psychiatric institutions commit suicide because of inadequate treatment and stigma from the society. Community does not accept deinstitutionalized people given their nuisance and these people end up being homeless and live in the streets where they die out of suicide, drug use or accidents.

Suicide rates are high to patients without people to care for them, and others die out infectious diseases such as TB given their living conditions. The results confirm the link between deinstitutionalization and stigma, inadequate treatment, homelessness, social isolation and increased suicides rate. Nurse practitioners indicated that ninety two percent of persons meant to be living in state-run psychiatric facilities are not living in these facilities. Most of these persons are released to the community where only a small percentage of them are accommodated in community health centers.

The population of mentally ill patient release to the community is higher than the number community health facilities can handle. According to NPs respondents, between fifty and sixty percent of deinstitutionalized people are critically mentally ill and cannot access treatment. Over half of these patients have serious illness such schizophrenia; ten to fifteen percent of the respondents suffer from manic-depressive sickness and severe depression.

Such patients are at risk of committing suicide given the seriousness of their illness and the fact that there are inadequate facilities to ensure them adequate treatment. Most mentally ill persons run.