Changing practice using recovery‐focused care in acute mental health settings to reduce aggression: A qualitative study

Consumer aggression is common in acute mental health settings and can result in direct or vicarious psychological or physical impacts for both consumers and health professionals. Using recovery‐focused care, nurses can implement a range of strategies to reduce aggression and empower consumers to self‐regulate their behaviour, when faced with challenging situations, such as admission to the acute care setting. Currently, there is limited literature to direct nurses in the use of recovery‐focused care and how it can be used to reduce consumer aggression. Twenty‐seven mental health nurses participated in this study. The constructivist grounded theory method guided data collection and analysis to identify categories that accurately described participants’ experiences. Five categories emerged that described how nurses can implement recovery‐focused care clinically to reduce the risk of consumer aggression: (i) identify the reason for the behaviour before responding; (ii) being sensitive to the consumer's trigger for aggression; (iii) focus on the consumer's strengths and support, not risks; (iv) being attentive to the consumer's needs; and (v) reconceptualize aggression as a learning opportunity. As the importance of promoting consumer recovery is now embedded in mental health policies internationally, nurses need to prioritize the application of recovery‐focused care clinically. Further research to provide evidence‐based outcomes supporting the use of recovery‐focused care is needed.     

A novel interprofessional approach to end-of-life care education: A pilot study

Abstract

Navigating the biomedical, emotional, and logistical complexity of end-of-life (EOL) care requires seamless interprofessional teamwork. Unfortunately, EOL care, interprofessional collaboration, and the role of support services such as hospice are not adequately emphasized in nursing and medical curricula. This article describes a student-run program, entitled the “HeArt of Medicine”, which was designed to foster a reflective and collaborative approach to EOL care. The program consists of three workshops with a novel blend of art, science, and practical information, highlighting the need for interprofessional teamwork. Participants were surveyed before and after the workshops on their attitudes toward EOL care. Composite participant scores after workshops demonstrated increased comfort with and knowledge of EOL care topics (p?=?0.001). The results show that this program has had a positive impact on participants’ knowledge, comfort, and collaboration in EOL settings.     

The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system

Stineman MG, Kwong PL, Kurichi JE, Prvu-Bettger JA, Vogel WB, Maislin G, Bates BE, Reker DM. The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system.

Objective

To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system.

Design

An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias.

Setting

Data compiled from 9 administrative databases from Veterans Affairs Medical Centers.

Participants

A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004.

Interventions

Not applicable.

Main Outcome Measures

One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year.

Results

After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups.

Conclusions

The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.     

Randomized crossover trial of kangaroo care to reduce biobehavioral pain responses in preterm infants: a pilot study

Kangaroo care (KC), skin-to-skin contact between mother and infant, is a promising method for blunting pain responses. This crossover pilot tested KC effects on biobehavioral responses to heel stick in preterm infants (30-32 weeks' gestational age, 2-9 days old) measured by Premature Infant Pain Profile (PIPP) and salivary and serum cortisol. Mother-infant dyads were randomly assigned to KC heel stick (KCH) first or incubator heel stick (IH) first. Study 1 (80-min study, N = 18) tested the effect of 80 min of KC before and throughout the heel stick procedure versus incubator care. Study 2 (30-min study, N = 10) tested 30 min of KC before and throughout the heel stick versus incubator care. KCH and IH began during a premeasurement phase and continued through four data collection phases: baseline, heel warming, heel stick, and recovery. PIPP responses were measured every 30 s during data collection; salivary cortisol was measured at the end of baseline and recovery; and serum cortisol was measured during heel stick. Study 1 showed no differences between KCH and IH. Study 2 showed lower PIPP scores at four time points during recovery (p < .05 to p < .001), lower salivary cortisol at the end of recovery (p < .05), and lower serum cortisol during heel stick for the KCH condition (p < .05) as well as clinically lower PIPP scores in the KCH condition during heel stick. Thirty minutes of KC before and throughout the heel stick reduced biobehavioral responses to pain in preterm infants.     

Getting it right: Educating professionals to work together in improving health and health care

Dedication

This paper is based on a lecture given by LAH as the 2nd John Horder lecture at Imperial College, London on 11 April 2006. Dr. Horder has been influential in improving patient outcomes in multiple ways, including his contributions to professional education. He was instrumental in the development of the Royal College of General Practitioners, serving as president from 1979–1982 and acting as a key leader in establishing post-graduate training for general practitioners in the United Kingdom. Dr Horder went on to found the Centre for the Advancement of Interprofessional Education, in part because of what he observed about the power of interprofessional collaboration in his own primary care practice. It was an honor to give a lecture in tribute to Dr John Horder. It was an opportunity to reflect on what we know about educating health professionals in training about the improvement of health care, including work I've helped to lead in the United States (where I now serve as the Senior Associate Dean for Education at the University of Missouri-Columbia School of Medicine). This paper also is dedicated to Dr. Horder.     

Older Persons Complex Care Nurse Practitioner model to reduce hospital readmissions: A pilot study

BackgroundPeople aged over 65 years are associated with increased numbers of co-morbidities, higher health care needs, an increased risk of fragmented care and are four times more likely to be hospitalised than those under 65 years. Nurse Practitioners (NP) working with older populations improved screening, clinical outcomes, patient satisfaction and provision of equal or better care for chronically ill patients.AimTo evaluate the effectiveness of the NP within the Older Persons Complex Care service to reduce hospital readmission rates in older complex patients.MethodsA pre and post pilot study using a retrospective clinical audit of medical records of patients referred to the NP service from January 2018 to April 2019 was undertaken. All patients reviewed by the NP were eligible for inclusion in the study and only those patients reviewed by the NP were included.FindingsSeventy seven patients were referred during the reporting period. Ages ranged from 64 to 98 years, and many co-morbidities were reported; minimum of two and maximum of 15 highlighting the complexity of the cohort. Management included education (100%), diagnostics (62%), medication changes (61%) and referrals (49%).DiscussionPatients managed within the service had reduced hospitalisations and many medications were ceased, reduced or titrated by the NP. Education was a key component of care.ConclusionThe value of NPs in the provision of care to older persons with complex, chronic diseases was highlighted with the potential to reduce readmissions, improve quality use of medicines and safe prescribing.     

Testing guidelines for child health care nurses to prevent nonsynostotic plagiocephaly: a Swedish pilot study

The aim of the study is to test effectiveness of guidelines for nurses that can be incorporated into the child health care program to prevent nonsynostotic plagiocephaly (NSP) in infants while still following sudden infant death syndrome-preventive recommendations. When guidelines were followed as intended in a Swedish pilot study, only 8.5% of infants had some degree of NSP at 6 months, compared to 25.6% of infants in the comparison group. Results indicate that the early and regular implementation of these guidelines by nurses may be an effective way to prevent NSP.     

Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital

Background/objectivesResearch indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients’ CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective.DesignA retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison.Setting/participantsA sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S.Methods/resultsNinety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR = 1.43, 95%CI 1.08–1.89, p = 0.012), being a male (OR = 3.14; 95%CI 1.40–7.05, p = 0.006), and the presence of two or more comorbidities (OR = 3.71, 95%CI 1.67–8.24, p = 0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation.ConclusionA positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.     

Experiences of adolescents with Cystic Fibrosis during their transition from paediatric to adult health care: a qualitative study of young Australian adults

Purpose:?Exploring the experiences of Australian adolescents with Cystic Fibrosis (CF) as they made the transition from paediatric to adult care. This often traumatic change of care was examined from the perspective of the two types of care, paediatric and adult, elements of a transition programme if available and psychosocial factors that may affect the transition.

Method:?Focused-in-depth interviews were conducted with six young adults with CF(19?–?34 years), asking them to describe their experiences during the transition period.

Results:?Thematic analysis of the transcribed interviews indicated that the four main areas that affected the transition experiences of the participants were paediatric and adult health care, the elements included in the transition programme, and psychosocial factors.

Conclusions:?The relationship of the patient with their paediatric doctor, the doctor's attitude towards the transition and the delivery of age-appropriate care appeared to influence the experiences of adolescents as they changed to adult care. Successful elements of a transition programme, if it was offered, were the orientation tours, the provision of information and the presence of a familiar face at adult clinics. Transition experiences of individuals had potential effects on their psychological and physical well-being so that, in order to maximize quality of care, health professionals must be aware of factors which may improve transition experiences.     

The teaching of health care ethics to students of nursing in the UK: a pilot study

Senior lecturers/lecturers in mental health nursing (11 in round one, nine in round two, and eight in the final round) participated in a three-round Delphi study into the teaching of health care ethics (HCE) to students of nursing. The participants were drawn from six (round one) and four (round three) UK universities. Information was gathered on the organization, methods used and content of HCE modules. Questionnaire responses were transcribed and the content analysed for patterns of interest and areas of convergence or divergence. Findings include: the majority (72.8%) of the sample believed that insufficient time was allocated to the teaching of HCE; case studies were considered a popular, although problematic, teaching method; the 'four principles' approach was less than dominant in the teaching of HCE; and virtue ethics was taught by only 36.4% of the participants. The Delphi technique proved adequate and worth while for the purposes of this study. Further empirical research could aim to replicate or contradict these findings, using a larger sample and recruiting more university departments. Reflection is required on several issues, including the depth and breadth to which ethics theory and, more controversially, meta-ethics, are taught to nursing students.     

Lesbian women's experiences with health care: A qualitative study

Background

Although the social situation for gay, lesbian, and bisexual people has improved over the last decades, lesbian women still face unique challenges when seeking healthcare services.

Objectives

To explore lesbian women''s healthcare experiences specifically related to sexual orientation to achieve knowledge which can contribute to increased quality of healthcare for lesbian women.

Methods

Qualitative study based on written stories, with recruitment, information, and data sampling over the internet. Data consisted of 128 anonymously written answers to a web-based, open-ended questionnaire from a convenience sample of self-identified lesbian women. Data were analysed with systematic text condensation. Interpretation of findings was supported by theories of heteronormativity.

Main outcome measures

Patients’ histories of experiences where a lesbian orientation was significant, when seeing a doctor or another healthcare professional.

Results

Analysis presented three different aspects of healthcare professionals’ abilities, regarded as essential by our lesbian participants. First, the perspective of awareness was addressed – is the healthcare professional able to think of and facilitate the disclosure of a lesbian orientation? Second, histories pointed to the attitudes towards homosexuality – does the healthcare professional acknowledge and respect the lesbian orientation? Third, the impact of specific and adequate medical knowledge was emphasized – does the healthcare professional know enough about the specific health concerns of lesbian women?

Conclusion

To obtain quality care for lesbian women, the healthcare professional needs a persistent awareness that not all patients are heterosexual, an open attitude towards a lesbian orientation, and specific knowledge of lesbian health issues. The dimensions of awareness, attitude, and knowledge are interconnected, and a positive direction on all three dimensions appears to be a necessary prerequisite.     

Intranasal hydromorphone for treatment of acute pain in children: A pilot study

ObjectivesWe aimed to describe the analgesic efficacy, duration of analgesia, and adverse event profile associated with intranasal hydromorphone in children with acute pain presenting to an emergency department.MethodsProspective dose titration pilot study of otherwise healthy children 4 to 17-years-old with moderate to severe pain who required a parenteral opioid. All patients received an initial intranasal hydromorophone dose of 0.03 mg/kg. The need for additional analgesia was assessed at 15 and 30 min; an additional 0.015 mg/kg was given at each assessment, if required. Need for rescue analgesic, pain intensity and adverse events were assessed until 6 h after hydromorphone administration or until patients were discharged, underwent a procedure to treat their painful condition, or received a rescue analgesic.ResultsWe enrolled 35 children. Fifteen, 11, and 9 children required a total dose of 0.03, 0.045, and 0.06 mg/kg, respectively. Patients in each dose group experienced an absolute decrease in pain score of ≥3/10 and percent reduction >40% within 5–15 min of completing dose-titration administration of hydromorphone. Duration of analgesia (i.e. time until rescue analgesic administered) >1 h was observed in 85.7% of patients. Patients not requiring rescue analgesics had mild or no pain until discharged or their painful conditions were treated. Three (8.6%) patients required a rescue analgesic <1 h after hydromorphone administration. There were no major adverse events.ConclusionsIntranasal hydromorphone led to rapid, clinically significant and frequently sustained decreases in pain intensity in children. No major adverse events were observed in this preliminary sample.Clinical Trials Registration Number: NCT02437669     

Recovery‐focussed care: How it can be utilized to reduce aggression in the acute mental health setting

Consumer aggression is common in the acute mental health inpatient setting. Mental health nurses can utilize a range of interventions to prevent aggression or reduce its impact on the person and others who have witnessed the event. Incorporating recovery‐focussed care into clinical practice is one intervention, as it fosters collaborative partnerships with consumers. It promotes their engagement in decisions about their care and encourages self‐management of their presenting behaviours. It also allows the consumer to engage in their personal recovery as their mental health improve. Yet there is a paucity of literature on how nurses can utilize recovery‐focussed care with consumers who are hospitalized and in the acute phase of their illness. In the present study, we report the findings of a scoping review of the literature to identify how recovery‐focussed care can be utilized by nurses to reduce the risk of consumer aggression. Thirty‐five papers met the inclusion criteria for review. Four components were identified as central to the use of recovery‐focussed care with consumers at risk of becoming aggressive: (i) seeing the person and not just their presenting behaviour; (ii) interact, don't react; (iii) coproduction to achieve identified goals; and (iv) equipping the consumer as an active manager of their recovery. The components equip nurses with strategies to decrease the risk of aggression, while encouraging consumers to self‐manage their challenging behaviours and embark on their personal recovery journey. Further research is required to evaluate the translation of these components clinically in the acute care setting.