Nursing migration: global treasure hunt or disaster‐in‐the‐making?

International nurse migration--moving from one country to another in the search of employment--is the focus of this article. The majority of member states of the World Health Organization report a shortage, maldistribution and misutilisation of nurses. International recruitment has been seen as a solution. The negative effects of international migration on the 'supplier' countries may be recognised today but are not effectively addressed. Nurse migration is motivated by the search for professional development, better quality of life and personal safety. Pay and learning opportunities continue to be the most frequently reported incentives for nurse migration, especially by nurses from less-developed countries. Career opportunities were considered key incentives for nurses emigrating from high-income countries. Language was reported to be a significant barrier. The positive global economic/social/professional development resulting from international migration needs to be weighed against a substantial 'brain and skills drain' experienced by supplier countries. The vulnerable status of migrant nurses is also of concern in certain cases. The focus on short-term solutions as opposed to resolving the problem of a worldwide shortage of nurses causes great concern. Recent initiatives attempt to curb or channel international recruitment. The delicate balance between recognising the right of individual nurses to migrate and a collective concern for the health of a nation's population must be achieved.     

Pacemaker‐mediated tachycardia in a dual‐lead CRT‐D: What is the mechanism?

A 73‐year‐old gentleman with dilated cardiomyopathy, left bundle branch block and a left ventricular (LV) ejection fraction of 20% was implanted with two LV leads in a tri‐ventricular cardiac resynchronisation therapy defibrillator (CRT‐D) trial. As a part of the trial he was programmed with fusion‐based CRT therapy with dual LV lead only pacing. The patient presented to local heart failure service 12 years after implant, after a positive response to CRT therapy, with increase in fatigue, shortness of breath and bilateral pitting oedema. The patient sent a remote monitoring transmission that suggested loss of capture on one of the LV leads. This coupled with atrial ectopics was producing a high burden of pacemaker‐mediated tachycardia (PMT) that was not seen when both LV leads had been capturing. What is the mechanism for this? Dual LV‐lead tri‐ventricular leads have been shown to have variable improvements in CRT response but with an increased complexity of implant procedure. This is the first case report of PMT‐induced heart failure exacerbation in a tri‐ventricular device following loss of LV capture of one lead.     

Are parent‐reported repetitive and restricted behaviours associated with psychological problems in pre‐school‐aged children?

This study surveys the association of restricted and repetitive behaviours in pre-school children with their emotional and behavioural problems. Parents of 504 pre-school children selected by cluster sampling participated and filled in the questionnaires including repetitive and restricted behaviour (RRB) scale and the Strengths and Difficulties Questionnaire. The parents reported repetitive and restrictive behaviours are gender-related in pre-school-aged children. Hyperactivity and emotional problems are significantly in association with all the four types of repetitive and restrictive behaviours. Prosocial problems score is in association with 'reaction to change' subscale score. Children with higher scores of conduct problems have higher rates of 'sensorimotor stereotypies', 'reaction to change' and 'modulation insufficiency'. Pre-school children with a higher rate of RRBs are more hyperactive and have more emotional problems than those with lower rates of RRBs. Conduct problems are more common in children with 'sensorimotor stereotypies', 'reaction to change' and 'modulation insufficiency' problems. Repetitive and restricted behaviours are associated with mental health problems in pre-school-aged children.     

Prophylaxis with low‐dose low‐molecular‐weight heparin during pregnancy and postpartum: is it effective?

Summary. Background: The optimal approach for venous thrombosis (VTE) prophylaxis during pregnancy and postpartum in women with an increased risk of VTE is not established. Objectives: To evaluate the effectiveness, represented as the incidence of pregnancy‐related VTE, and safety, represented as incidence of postpartum hemorrhage (PPH), of a protocol recommending prophylaxis with low‐dose low‐molecular‐weight heparin (LMWH) in women at intermediate to high risk of VTE. Patients/methods: In this retrospective cohort study, we analyzed 34 women (44 pregnancies) with intermediate risk of VTE who received low‐dose LMWH for 6 weeks postpartum and 57 women (82 pregnancies) with high risk of VTE who received low‐dose LMWH during pregnancy and for 6 weeks postpartum. Pregnancy‐related VTE was defined as VTE during pregnancy or ≤ 3 months postpartum. PPH was defined as blood loss > 500 mL and severe PPH as blood loss > 1000 mL. Results: The incidence of pregnancy‐related VTE was 5.5% (95% CI, 2.4–12.3) despite prophylaxis with low‐dose LMWH. All events occurred in women at high risk, with a postpartum incidence of 7.0% (95% CI, 2.9–16.7) and antepartum incidence of 1.8% (95% CI, 0.4–9.2). The risk of PPH was 21.6% (95% CI, 14.3–31.3) and severe PPH 9.1% (95% CI, 4.7–16.9), which was not different in women who started LMWH postpartum and those who used LMWH during pregnancy. Conclusions: Although prophylaxis with low‐dose LMWH during pregnancy and postpartum proved to be safe, the risk of pregnancy‐related VTE is considerable in women with a high risk of VTE. VTE prophylaxis with low‐dose LMWH may not be sufficiently effective in these women.     

Combat‐Related Blast‐Induced Neurotrauma: A Public Health Problem?

The purpose of this article is to raise nurses' awareness of the significance and potential public health impact of combat-related blast-induced neurotrauma (BINT) in U.S. troops returning from Afghanistan and Iraq. A comprehensive review of the current literature on BINT was completed by the author, based primarily on combat-related blast exposure in the military population. She found that it is necessary to theorize about potential etiologies for mild traumatic brain injury in the military population since the literature suggests that neurological and psychological trauma resulting from military duty may be linked to exposure to blasts. Identification of potential risk factors for BINT in the military population provides direction for scientific inquiry into this emerging phenomenon. Gaps in current knowledge and its health implications for future scientific study in nursing are presented.     

Is modified brief assertiveness training for nurses effective? A single‐group study with long‐term follow‐up

Aim

To evaluate the long‐term effectiveness of modified brief assertiveness training (with cognitive techniques) for nurses.

Background

Most assertiveness training takes a long time to conduct; thus, briefer training is required for universal on‐the‐job training in the workplace.

Methods

In this single‐group study, nurses received two 90‐min training sessions with a 1‐month interval between sessions. The degree of assertiveness was assessed by using the Rathus Assertiveness Schedule as the primary outcome, at four time points: pre‐ and post‐training, 3‐month follow‐up and 6‐month follow‐up.

Results

A total of 33 nurses received the training, and the mean Rathus Assertiveness Schedule score improved from ?14.2 (SD  = 16.5) pre‐training to ?10.5 (SD  = 18.0) post‐training (p  <  .05). These improvements were maintained until the 6‐month follow‐up. The pre–post effect size of 0.22 (indicating small effect) was larger than the effect sizes ranging from ?0.56 to 0.17 (no effect) reported in previous studies that used brief training.

Conclusions

Modified brief assertiveness training seems feasible and may achieve long‐term favourable outcomes in improving assertiveness among nurses.

Implications for Nursing Management

The ease of implementation of assertiveness training is important because creating an open environment for communication leads to improved job satisfaction, improved nursing care and increased patient safety.

     

Drugs and blood transfusions: dogma‐ or evidence‐based practice?

summary .  There is a lack of consensus on the safety of the coadministration of drugs and red blood cells (RBCs). A systematic review was undertaken to establish the evidence base for this question and assess how the evidence may be translated into present clinical day practice. Comprehensive searches of MEDLINE, EMBASE, CINAHL, the Cochrane Library and hand searching of transfusion journals, guidelines and websites identified 12 relevant papers: 11 in-vitro experiments and 1 case report. Data on incidences of haemolysis and agglutination following coadministration were extracted and analysed. Overall findings suggest that iron chelators (two papers), antimicrobials (three papers) and lower doses of opioids (three papers) are safe to coadminister with RBCs. Haemolysis was observed with higher doses of opioids (three papers). Transposition of these findings to clinical practice is limited because of the lack of clinical applicability of in-vitro experiments and diversity in how, and what, clinical outcome measures were used. Further evidence from true clinical settings would be required to inform clinical practice on the efficacy and safety of the coadministration of drugs and RBCs.     

Brain‐based treatment—A new approach or a well‐forgotten old one?

For a relatively long period of time, mental functioning was mainly associated with personal profile while brain functioning went by the wayside. After the 90s of the 20th century, or the so called “Decade of the Brain”, today, contemporary specialists work on the boundary between fundamental science and medicine. This brings neuroscience, neuropsychology, psychiatry, and psychotherapy closer to each other. Today, we definitely know that brain structures are being built and altered thanks to experience. Psychotherapy can be more effective when based on a neuropsychological approach—this implies identification of the neural foundations of various disorders and will lead to specific psychotherapeutic conclusions. The knowledge about the brain is continually enriched, which leads to periodic rethinking and updating of the therapeutic approaches to various diseases of the nervous system and brain dysfunctions. The aim of translational studies is to match and combine scientific areas, resources, experience and techniques to improve prevention, diagnosis and therapies, and “transformation” of scientific discoveries into potential treatments of various diseases done in laboratory conditions. Neuropsychological studies prove that cognition is a key element that links together brain functioning and behaviour. According to Dr. Kandel, all experimental events, including psychotherapeutic interventions, affect the structure and function of neuronal synapses. The story of why psychotherapy works is a story of understanding the brain mechanisms of psychic processes, a story of how the brain has been evolving to ensure learning, forgetting, and the mechanisms of permanent psychological change. The new evidence on brain functioning necessitates the integration of neuropsychological achievements in the psychotherapeutic process. An integrative approach is needed to take into account the dynamic interaction between brain functioning, psyche, soul, spirit, and social interaction, ie, development of a model of psychotherapeutic work based on cerebral plasticity! Brain‐based psychotherapy aims at changing brain functioning not directly, but through experiences. This is neuro‐psychologically informed psychotherapy.     

Meta‐analysis: the glass eye of evidence‐based practice?

Meta-analysis was developed as a technique for combining the results of many different quantitative studies: it is often used to produce quantitative estimates of causal relations and/or association between variables. Meta-analysis is sometimes regarded as a central component of evidence-based practice. We draw attention to an incompatibility in the epistemology and methods of reasoning in quantitative meta-analysis and the epistemology and reasoning implicit in expert practice. We argue that this may be because the common perception of meta-analysis appeals to truth as correspondence; we suggest that rejecting the naive realism that underpins truth as correspondence allows meta-analysis to be understood in terms of truth as coherence. We can then develop an account of meta-analysis that does not depend upon reduction to a mathematical procedure but is an attempt to maximise coherence in beliefs about what works that is consistent with clinical reasoning in expert practice.     

Biosimilars of low‐molecular‐weight heparin products: fostering competition or reducing ‘biodiversity’?

The term ‘biosimilars’ is used to qualify products developed to be similar to an original biological drug. Biosimilars are much more complicated to develop than a generic version of small‐molecule drugs and this is especially true for low‐molecular‐weight heparins (LMWHs). Evidence on the antithrombotic management of acute coronary syndromes (ACS) showed that the introduction into the market of biosimilars approved on the basis of simple biological criteria, without robust data from comparative clinical trials, may be hazardous. Moreover, the mixtures of LMWH polysaccharide chains, some immunoallergic properties and potential contamination during the extraction process raise safety concerns. As was the case for the biosimilar erythropoietin, there is the risk that only copies of the most commercially successful LMWHs will be marketed, thus jeopardizing the ‘biodiversity’ now ensured by the presence of several LMWHs, each with unique features that support the use of an individual LMWH as first‐choice therapy in certain categories of patients.     

Do ‘no‐suicide’ contracts work?

Suicide is the main cause of premature death in mental health service users, and the prevention of suicide is a major, global concern. An intervention designed to address this concern is the 'no-suicide' contract (NSC) – an agreement, usually written, between a mental health service user and clinician, whereby the service user pledges not to harm himself or herself. Following a review of the literature on NSCs, this paper argues that there is a lack of quantitative evidence to support such contracts as clinically effective tools and that there is strong opposition to the tool, from both service users and nurses. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection and the ethical implications of restricting a service user's choices when they may be already struggling for control. In light of these findings, the paper discusses alternative interventions aimed at preventing self-harm and suicide. Although a number of other interventions are available to clinicians, further research is required to test the effectiveness of these as viable alternatives to the NSC.