It isn't something to yodel about, but it exists! Faeces, nurses, social relations and status within a mental hospital

In medical settings, emotion-provoking work creates a hierarchy among health care professionals. "Lower" emotions like disgust, contempt or aversion that are evoked by "body work" with elderly patients often remain invisible, but they play an important role in morality and shape the social relations between the patients and the professionals. With the help of ethnographic data from the nursing wards of a mental hospital, the author shows how feelings about excrement are determined not only by their nature, but also by the nature of the relationships among the nurses and the relationships between the nurses and the elderly patients. Body care and the emotions that are evoked are connected to morality and moral care. Dealing with bodily and moral "dirt" gives nurses a special position within the hospital as a whole, which will have effects on the care for elderly.     

Identification of psychological morbidity in older people in primary care by practice nurses

Older people with psychological morbidity generally first present to health services in primary care, where they are increasingly seen by primary care nurses. In order to evaluate primary care nurses' identification of psychological morbidity, 190 older patients attending eight practice nurses completed the General Health Questionnaire (GHQ) and the practice nurses made an assessment as to the presence or absence of psychological problems. The practice nurses identified only 26% of probable cases of psychological morbidity identified by the GHQ. Their threshold for identification was high, rating only 12% of patients as experiencing psychological problems compared to 29% probable cases identified by the GHQ, and their accuracy was low (kappa for agreement between GHQ and nurse ratings = 0.23). Likelihood of identification depended on length and type of visit. The findings suggest that it may be unrealistic to expect practice nurses, without additional training and reorganisation of their work, to identify more than a minority of older patients with psychological morbidity in the course of their routine work.     

The roles of knowledge and supervision in work with suicidal patients

Despite caregivers' impact on suicidal patients' compliance with treatment and suicide prevention, little is known about mental-health professionals' perceptions of work with suicidal patients. The roles of psychiatric staff's training and supervision in the care of suicidal patients were investigated by means of a postal questionnaire sent to a random sample of 1543 psychiatric staff members. The response rates were 71% for psychiatrists and 57% for nurses and assistant nurses. The responses of 53 psychiatrists, 164 nurses and 333 assistant nurses working with suicidal patients on a regular basis were compared and analysed using the Kruskal-Wallis test. Thirty-five per cent of the assistant nurses, 43% of the nurses and 74% of the psychiatrists who worked with suicidal patients on a regular basis perceived that they were sufficiently trained for this work, while 75% of the assistant nurses, 72% of the nurses and 34% of the psychiatrists received supervision in their work with suicidal patients. In spite of receiving supervision, nursing staff who perceived that they lacked training reported uncertainties in their work with suicidal patients to a larger extent than those who perceived that their training was sufficient. Uncertainties were significantly more prevalent among nursing staff than among psychiatrists. Basic and specific training in suicidology is needed and cannot be replaced solely by supervision, since psychiatric staff often have to deal with suicidal patients in emergency situations and must be able to rely on their own skills.     

Book Reviews

Despite caregivers' impact on suicidal patients' compliance with treatment and suicide prevention, little is known about mental-health professionals' perceptions of work with suicidal patients. The roles of psychiatric staff's training and supervision in the care of suicidal patients were investigated by means of a postal questionnaire sent to a random sample of 1543 psychiatric staff members. The response rates were 71% for psychiatrists and 57% for nurses and assistant nurses. The responses of 53 psychiatrists, 164 nurses and 333 assistant nurses working with suicidal patients on a regular basis were compared and analysed using the Kruskal-Wallis test. Thirty-five per cent of the assistant nurses, 43% of the nurses and 74% of the psychiatrists who worked with suicidal patients on a regular basis perceived that they were sufficiently trained for this work, while 75% of the assistant nurses, 72% of the nurses and 34% of the psychiatrists received supervision in their work with suicidal patients. In spite of receiving supervision, nursing staff who perceived that they lacked training reported uncertainties in their work with suicidal patients to a larger extent than those who perceived that their training was sufficient. Uncertainties were significantly more prevalent among nursing staff than among psychiatrists. Basic and specific training in suicidology is needed and cannot be replaced solely by supervision, since psychiatric staff often have to deal with suicidal patients in emergency situations and must be able to rely on their own skills.     

Mental health support for nurses

Burnout specific to human service workers has been reported in the U.S. in the 1970s. Since then, such burnout has become widely known and the mental health of nurses has attracted attention. Stressors in the work environment and complexity have increased with advancement in increasingly complicated medical care. One of the major roles of a psychiatric liaison nurse is to provide support to improve the mental health of nurses. In our hospital, a psychiatric liaison nurse has a staff position under the direct supervision of the director of the nursing department but operates outside the chain of command. A psychiatric liaison nurse is not involved in the performance review of nurses. Thus, the nursing staff and the nursing manager can discuss their problems with the psychiatric liaison nurse without risks. Psychiatric liaison nurses provide support as counselors through individual and group interviews so that nurses can become re-energized about their work. In addition, psychiatric liaison nurses provide consultations and education. They perform coordination function to organize an environment to promote consultations regarding nurse support to the staff nurses and the nursing manager and to promote support by supervisors. For support after reinstatement of a nurse following a medical leave, it is particularly important to work with not only the individual nurse but also the entire nursing team. In our hospital, newly graduated nurses are given the GHQ-28 after one month of employment to assess the support they might need. In our study, nurses with high risks were divided into a group with a score of at least 6 points but less than 10 points and a group with a score of at least 10 points. The group with at least 10 points had significantly higher rates of leave of absence and resignation. Thus, early intervention was thought to be necessary in newly graduated nurses with a score of at least 10 points in the GHQ.     

Caring for people with developmental disabilities: survey of nurses about their education and experience

Over 500 nurses in New Jersey responded to a survey on education and training in the area of developmental disabilities. Respondents provided information on their work experience, experience with patients who have developmental disabilities, and opportunities for continuing medical education. Results showed that although many nurses thought educational activities related to developmental disabilities were important, only about 10% said that they received "a lot" of training. Most respondents (almost 60%) said that they received little or no training in the area, and most received no specific training on developmental disabilities since receiving their licenses or in their current job. Implications of these findings in light of the movement of people with developmental disabilities into community-living and managed care plans are discussed.     

The Alcohol Smoking and Substance Involvement Screening Test (ASSIST) in an Acute Mental Health Setting

Up to sixty percent of people admitted to acute mental health services in Australia present with a clinically significant co-occurring drug and/or alcohol problem. These individuals experience poorer health outcomes when compared to the general population and to those people who have a mental illness but have no co-morbid alcohol and drug problems. Anecdotal evidence also suggests that many nurses working in the area do not have the knowledge and skills and confidence to work effectively with this patient population. Drug and alcohol assessment tools, considered the gold standard, generally assess only one substance at a time or provide little specific information on the particular substance of use or abuse. An amended version of the World Health Organisation, (WHO) Alcohol Smoking and Substance Involvement Screening Test Version 3 (ASSIST V3.0) and associated brief interventions was implemented following an in-vivo education program at an acute mental health inpatient unit in Western Australia. This before and after intervention’ study utilised a self-rating questionnaire and a knowledge quiz to assess nurses’ knowledge of drug and alcohol issues as well as their level of confidence to work with people who have a mental illness and co-occurring drug and alcohol problems. Translation of acquired knowledge into patient care was also evaluated through a review of patient medical records. Significant improvement in nurses’ knowledge was reported along with increased clinical confidence and skills to identify, assess, and manage this group of patients and to provide them with information and referral to appropriate agencies in the community.     

Enhancing primary health care services for adults with intellectual disabilities

Background Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training needs, and self-efficacy in their work with people with ID. Methods All practice nurses working in a defined area were identified. A purpose-designed questionnaire to measure nurse attitudes, knowledge, training needs and self-efficacy was developed and piloted. All practice nurses were then invited to participate. Data from completed questionnaires were entered onto PC and analysed. Results Of a total of 292 practice nurses 201 (69%) participated. Whilst 89% (n = 179) of participants reported having infrequent contact, 25% (n = 50) reported a growing workload with people with ID. Only 8% (n = 16) had ever received any training in communicating with people with ID. A knowledge gap regarding the health needs of people with ID was identified. Eighty-six per cent reported having experienced specific difficulties during previous appointments, and only 23% thought they had sufficient case note information at appointments, but 68% did not modify the duration of their appointments with people with ID. Conversely, responses demonstrated that practice nurses have a high level of experience and qualification in general nursing, have positive attitudes to working with people with ID, and high self-efficacy scores were identified for work with people with ID. The practice nurses viewed ID to be a high priority area for future training. Conclusions Primary health care teams have a key role in tackling the unmet health needs of people with ID. Whilst this project has identified factors that may impact on the accessibility of services, it has also identified practice nurses as having positive attitudes and high self-efficacy scores in their work with people with ID. This indicates that they should be targeted for specific training in this area, which may make an important contribution in enhancing future accessibility of primary health care services for people with ID.     

Comparative study of actigraphy and ambulatory polysomnography in the assessment of adaptation to night shift work in nurses

Night shift work is common in hospitals to assure continuous care. This practice, however, induces difficulties due to changes in the sleep/awake cycle of hospital workers. The aims of the present study were to validate actigraphy in comparison with polysomnography for sleep evaluation and to assess nurses' adaptation to sleep/wake cycles when on a permanent night shift schedule. Actigraphy and ambulatory polysomnography were performed in fifteen night shift nurses employed in hospital on a full time basis, during their work and their rest periods. Our first findings showed that actigraphy gave reliable results compared with polysomnography in evaluation of total sleep time. In addition, it was found that seven of the nurses exhibited, during their work periods, an approximately five-hour delay in the acrophase of their rest/activity rhythm compared with their rest periods. In contrast, five other nurses whose acrophase did not change between work and rest periods, exhibited sleep episodes of more than 100 minutes duration at work. These results confirm data in the literature and show that some nurses cannot adjust the circadian rhythm of their inner biological clock to their nocturnal schedules. Actigraphy seems to be an efficient, low cost and easy method for measuring total sleep time as well as for assessing the inability of nurses to adapt to permanent night shift work.     

Survey of attitudes of nurses working with AIDS patients

This article reports the results of a ten-question anonymous survey given to nurses at Westchester County Medical Center in July 1983 and January 1984 concerning attitudes about caring for AIDS patients. Two-thirds of the responding nurses reported that they had friends or family express concern about associating with hospital personnel who have contact with AIDS patients. Other questions showed that between one fourth and one half of nurses have a fear of caring for homosexual men and male prisoners because of their awareness about AIDS. One half of the nurses believe that AIDS can be transmitted to hospital personnel because of contact with patients despite precautions. The fear of caring for patients with AIDS as compared to caring for patients with hepatitis, a more contagious but less serious disease than AIDS, was highest in the intensive care unit staff. Eighty-five percent of the health care personnel responding believed that pregnant nurses should not care for AIDS patients and one half of the nurses responding indicated that they would ask for a transfer if they had to care for AIDS patients on a regular basis. The implication of these findings for future treatment programs, medical and nursing education and psychologic support for staff are discussed.     

Stresses and coping in ICU nursing: Why support groups fail

A successful nurse support group was contrasted with two unsuccessful support groups. The authors concluded that support groups work best if they are initiated in response to a felt need by the nurses, if the nurses have experienced the group leader as helpful in the past, if the group is highly structured and does not allow early discharge of intense negative feelings, and if the group's problems are primarily interpersonal and can be dealt with in the group and not primarily environmental or administrative problems such as noise, overcrowding, or understaffing.     

Abortions and acute identity crisis in nurses

About a month after Hawaii became the first state in the U.S. to make abortion a personal matter to be decided between a woman and her physician, 2 hospitals, in efforts to obtain psychiatric consultation for their nurses who were upset by abortion work, contacted the authors. 2 nurses in a small hospital which had been doing abortions were also interviewed by 1 of the authors. All the nurses interviewed suffered from strong emotional reactions, including anxiety and depression. The strong reactions were unexpected by some of the nurses, although many of them had approved of the new abortion law before it went into operation. Other problems included overidentification with the aborted fetus, hostility toward most of the abortion patients, and acute identity crisis regarding nursing role and function (e.g., conflict between training to save life and job to terminate it, resentment of physician). Resolution of the problems made use of abreaction and the psychiatrists as positive therapeutic figures. The nurses reestablished a more positive identification with their patients and regained objectivity about abortions. The authors recommend that adequate time and effort should be spent helping nurses prepare for their role when an institution begins to perform unrestricted abortions.     

Are you ready (to be a neuroscience nurse)?

On the pediatric neurosciences unit of British Columbia's Children's Hospital we are in the throes of a nursing staff crisis. In the last year alone we hired ten new graduates to work as casuals on our unit. With a two and a half day hospital orientation, five preceptor shifts, and a Competency Based Education Plan in hand, we send them off to the trenches. We know these nurses have little nursing experience and even less Neuroscience nursing experience. Yet, we expect them to care for patients and families whose problems they may not understand. For a preceptor, and senior colleague, this is a disturbing situation. We recognize that in their orientation shifts they have not even begun to experience the challenges of a Neuroscience unit. Have they cared for a child who has had a postoperative laminectomy? Do they recognize subtle seizures? Have they sat with a family who have just learned that their child has a brain tumor? No. We expect them to care for patients and families with minimal support. This is the reality of nursing today. Many of us pride ourselves on being committed pediatric Neuroscience nurses. Our physicians rely upon our assessment skills and they trust our intuition! We believe we have earned that trust. How can we convey our enthusiasm and excitement to our perceptees so they are motivated to stay and become experienced pediatric Neuroscience nurses? In this presentation we outline our paper to remedy this situation.     

A Qualitative Study of Factors Influencing Psychiatric Nursing Practice in Australian Prisons

TOPIC: Factors influencing the practice of psychiatric nursing in Australian prisons. METHODS: A qualitative study of psychiatric nurses (N = 30) working in a prison. FINDINGS: The psychiatric nurses identified the following factors as influencing their work: challenging patients, threats to personal survival of patients, the technology and artifice of confinement, conflicting values of nurses and corrections staff, stigma by association, and prisoner identification of the nurses with prison administration. CONCLUSIONS: Psychiatric nurses who work in forensic settings must adapt to less than optimal practice conditions.     

Attitudes of Japanese nursing personnel toward patients who have attempted suicide

Objective

The aim of this study was to examine the attitudes among Japanese nurses together with their perceived need for training in relation to understanding the nature of suicidal behavior and preventive strategies.

Methods

The Understanding Suicidal Patients scale together with additional questions reflecting training and the psychiatric treatment of suicide attempters were administered.

Results

A total of 323 nurses attended this study. Overall, the nurses thought patients who attempted suicide were not treated well. The nurses who worked in the psychiatric unit or had the experience in psychiatric nursing had more favorable attitudes toward suicidal patients and viewed themselves as having more relevant skill training in dealing with suicidal patients than those who did not. The nurses who worked at emergency care/intensive care unit were less likely to understand suicidal patients, and were less inclined to be sympathetic and to verbally interact with suicidal patients concerning their problems. The nurses who have confidence in the psychiatric care of suicidal patients, confidence in their own skills, and have a need for more training had the more positive attitudes.

Conclusions

The results suggest that less favorable attitudes may to some extent be the result of lack of knowledge regarding suicidal patients. Future studies should focus on the evaluation of educational experiences on attitudes and skill acquisition of nurses.     

Assessment of PTSD symptoms in emergency room, intensive care unit, and general floor nurses

A total of 125 registered nurses participated in an investigation of Posttraumatic Stress Disorder (PTSD) related symptoms and various levels of nursing care. The sample included 43 emergency room nurses (ER), 51 intensive care unit nurses (ICU), and 31 general floor nurses (GF). All participants were assessed on measures of PTSD, social support, dissociation, anxiety, depression, and demographics. Contrary to expectations, the ER nurses were not found to be uniquely stressed by their work when compared to the other nursing groups. Results indicated that all nurses experienced a significant level of anxiety but were not in the clinically significant range for PTSD, depression, or dissociation. It was inferred that social support played a significant role in helping nurses cope with work-related stress. Nevertheless, the high anxiety levels of all nurses were highlighted as a concern. It was suggested that exposure to numerous traumatic experiences over a lifetime of nursing, and a lack of control over these experiences, contributed to the high anxiety levels seen in all nursing groups.     

An Analysis of Australian Mental Health Services for people with Mental retardation

This paper reports the findings of a survey of a representative sample of institutionally based nursing staff who work with patients who have developmental disability (DD). The survey investigated nurses’ knowledge, attitudes, preparation and skills with regard to patients who have dual diagnoses of epilepsy and DD and identified some significant deficiencies in these domains. Based on these findings, the paper indicates a need to establish appropriate training programs for nurses so that the needs of these patients can be better addressed.     

Interventions to alleviate patients' stress: A review

Many events occuring in hospital have been found to be stressful for patients. Interventions aimed at alleviating these reactions have, in the main, been evaluated by psychologists and nurses. Methods used and contrasting approaches are reviewed. Although surgery has been the main event for this research, special investigations, treatments and hospital admission and discharge have also been studied. Outcome criteria have varied with physical measures being used more by nurses. Emphasis has been placed on preventing complications rather than enhancing recovery. Recent work has tended to compare types of intervention. Focused positive reappraisal and information on sensations are provided rather than procedural details as they have been found more successful in alleviating stress.     

The nebulous scope of current psychiatry

Psychiatry as practiced today has the appearance of a disturbing set of unrelated activities, at least to the casual observer. Psychiatrists involve themselves in the most unlikely undertakings and quite often seem to have in common only their membership in the medical profession. Some adhere to the psychoanalytic field, deal only with intrapsychic conflicts, and, therefore, refrain from medical practices. Others become administrators of community services or community psychiatrists who intrude upon the field of social scientists and emphasize the social causation of mental disorders. They may also neglect all contact with medical disciplines and even forget their clinical skills. For some of them, as Dunham¹ has said, it has become fashionable to measure their success in having no contact with patients. There is still a third group of psychiatrists who profess a pure biologic orientation and may disregard entirely the social and psychodynamic aspects of psychiatry. With few exceptions the representatives of these extreme attitudes behave as if they were living and working in total isolation and rarely exchange their scientific achievements.Mental disorders are diversely conceived as mental illnesses, maladaptive habits learned in pathological social environments, and even as normal reactions to abnormal social influences which should not be corrected since they have a curative goal. The object of these baffling conceptions is variously named “patient,” “deviant,” “client,” “troubled person,” “alienated human being,” and even “consumer,” and his problems dealt with accordingly in quite different ways. We often see severely disturbed patients who go to a hospital to request medical treatment and have to face the astonishing situation of being assigned to a nonmedical member of the psychiatric team, against all traditional ways of thinking. We work in hospitals, but wear no white coats and even encourage the nurses on psychiatric wards to throw away their uniforms. It is no wonder that the role of the psychiatrist appears to be at stake in the midst of these chaotic conflicting attitudes and that uncertainty pervades psychiatry today.     

Patient perspectives on the diagnosis, treatment, and management of bipolar disorder

Objective:  To compare the needs of patients and with those cited by psychiatrists in the current physician study to provide a more balanced view of the scope of unmet needs.
Methods:  A US-based consensus panel categorized unmet needs according to their relevance to patients, providers, or health systems.
Results:  Patients need medications that are quicker acting, have less troublesome side-effects, are more effective, and are significantly less expensive, and they need access to medications most likely to help them by not being at the mercy of restricted formularies. To improve communication with patients, physicians must not only listen more effectively but must also ask patients more direct and targeted questions, particularly regarding all symptoms the patient might be experiencing. Patients gave a high priority to making treatment decisions jointly with their physicians and being partners in their wellness plan. Peer support can also be extremely helpful to people who have bipolar disorder.
Conclusions:  By making efficacious, affordable medications available, improving communications, jointly creating wellness strategies and goals, and equally participating as active partners, patients and physicians can work together to achieve optimal wellness not just remission of symptoms.