Managing risk: clinical decision-making in mental health services

Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.     

Interpretation and management of positive anti‐hepatitis B core antibody tests in immunocompromised pediatric patients

Intravenous immunoglobulin (IVIg) therapy is increasingly used in the pediatric population, in particular among children with immune‐compromising conditions. Pooled immunoglobulin products are routinely tested for hepatitis B surface antigen (HBsAg) and nucleic acid; however, screening for hepatitis B core antibody (anti‐HBc) is not commonly performed. Thus, the administration of IVIg containing anti‐HBc to children with immune‐compromising conditions may complicate the interpretation of hepatitis B serologic testing in that a positive anti‐HBc test may represent passive transfer of antibody from IVIg or may indicate resolved or chronic hepatitis B infection. Due to the risk of hepatitis B reactivation in immunocompromised patients, a positive anti‐HBc test must be carefully considered. As part of a quality improvement initiative, we identified and reviewed the records of all pediatric patients at our institution who tested positive for anti‐HBc over an 18‐month period. Of 44 total patients with positive anti‐HBc tests, we found that 22 (50%) had previously received IVIg in the preceding 4 months. All but one of these, 21/22 (95%), went on to receive immunosuppressive therapy (IS). Among the patients who received IS, 19 (86%) had not undergone hepatitis B serologic testing prior to IVIg administration and 16 (73%) did not have subsequent testing to distinguish between passive acquisition of anti‐HBc from IVIg and chronic hepatitis B infection. Our single‐center experience reveals that a high proportion of positive anti‐HBc tests in children are presumed to be because of the passive antibody transfer from IVIg. However, a low proportion of patients undergo confirmatory testing, despite the risk of hepatitis B reactivation during IS. We thus propose a risk‐based algorithm for interpretation and monitoring of hepatitis B testing in immunocompromised children.     

Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards

There is disagreement among psychiatric professionals about whether the doors of acute psychiatric wards should be kept locked to prevent patients from leaving and harming themselves or others. This study explored patient, staff, and visitor perceptions about the acceptability of locking the ward door on acute psychiatric inpatient wards. Interviews were conducted with 14 registered nurses, 15 patients, and six visitors from three different acute wards. Findings revealed commonalities across all groups, with general agreement that locking the door reduced absconding. Staff expressed feelings of guilt, embarrassment, and fear of being blamed when a patient absconded. Staff also reported that open wards created anxious vigilance to prevent an abscond and increased workload in allocating staff to watch the door, whereas staff on partially-locked doors also perceived an increased workload in letting people in and out of the ward. Patients had mixed feelings about the status of the door, expressing depression, a sense of stigma, and low self-esteem when the door was locked. The issue of balancing safety and security on acute psychiatric wards against the autonomy of patients is not easily resolved, and requires focused research to develop innovative nursing practices.     

Medical co-morbidity risk factors and barriers to care for people with schizophrenia

The management of risk is a fundamental component of the work of mental health nurses and is most commonly associated with aggressive, violent and suicidal behaviours exhibited by those suffering from mental illness. However, people with severe mental illness are increasingly at risk of experiencing a number of related and complex health problems that include obesity, diabetes and cardiovascular disease. This group also has much higher rates of morbidity and mortality than that of the general population resulting in high social, economic and individual costs. Some of the barriers to receiving prompt and appropriate physical health care include lack of recognition by health professionals and the difficulties faced by consumers of mental health services in negotiating the health care system. Establishment of comprehensive (addressing both physical and mental health issues) programmes of care can address this need and offer additional opportunities for closer and more collaborative nurse-patient relationships. This paper explores risk factors for medical co-morbidity for people living with schizophrenia and suggests strategies that can facilitate better health outcomes.     

Treading lightly: spirituality issues in mental health nursing

ABSTRACT: Spirituality has been recognized as an important part of nursing practice since its early beginnings. However, debate continues about whether and how nurses and other mental health professionals should include spirituality within their daily work. This paper aims to contribute to the discussion of spirituality within mental health nursing, through considering findings from a Heideggerian phenomenological study conducted with six people with mental illness living in regional Australia. This study aimed to provide a greater understanding of the phenomenon of spirituality by answering a primary research question, ‘What does spirituality mean for people with a mental illness?’ Participants were interviewed and data analysed using an iterative approach. Findings emerged through multiple readings and meanings were gradually constructed from the data into themes. The themes describe that spirituality is experienced uniquely for the participants, and that spirituality became vitally important to them when they became mentally unwell. In addition, issues of interest to mental health nurses were raised but not completely addressed by the study. The issues relate to potential interactions about spirituality between nurses and their patients. Although participants wanted to discuss their experiences of spirituality with others, they raised concerns about whether their mental health care providers would be accepting of their beliefs. Spirituality was deemed to be a highly individual phenomenon; it could be experienced as a journey and it was life‐sustaining. For these reasons, it is proposed that mental health professionals must be prepared to discuss patients’ spiritual needs in the context of their health concerns.     

Towards a scientific rationale for traditional properties of Chinese medicinal plants: a€?naturesa€? and a€?flavorsa€?

ObjectiveAccording to theory of Chinese medicine property, the ecological environment shapes properties (natures and flavors) of Chinese materia medica (CMM) and there are close relationships between certain natures and flavors. However, to date these observations have not been validated scientifically in the context of the whole flora of a region. The present study aims to address this gap.MethodsWe collected geographical distributions of 3637 vascular plant species native to the Xinjiang region of northwest China, of which around 812 are medicinal plants. The CMM property characters of these medicinal plants were also collected. All medicinal plants were then analyzed in the occurrence of their natures (cold, cool, neutral, warm, and hot) and flavors (sweet, bitter, sour, salty, and pungent). Possible correlations between these properties and environmental factors, notably climate, as well as correlations with plant species richness of the wider native flora of Xinjiang were then investigated using permutation test and regression.ResultsCold species (38.5%) were more numerous than warm (21.0%) and neutral (22.3%), while bitter species (43.3%) were more numerous than pungent (25.6%), sweet (22.4%) and sour (6.7%) ones. Species with bitter flavor were most commonly also cold (48.6%) in nature, sour flavor usually coincided with cold (44.2%) or cool nature (26.0%), whereas pungent or sweet species tended to be warm (34.4%, 28.4%) or neutral (27.8%, 28.4%). The percentages of species of cold/cool nature, bitter flavor were higher in mountainous regions, and the percentages of warm/neutral and pungent/sweet/sour were higher in basins. The percentages of species of bitter, cold/cool, bitter were positively correlated with actual evapotranspiration (AET), plant species richness andbut had a bell-shaped relationship with potential evapotranspiration (PET), whereas the inverse situation was shown for warm/neutral and pungent/sweet/sour species.ConclusionAnalysis of the data in Xinjiang region of China supports the qualitative observations concerning natures and flavors in traditional theory of Chinese medicine property. Specifically, (i) certain natures and flavors co-occur more frequently than if randomly distributed; (ii) correlations between proportions of natures and flavors and climatic variables suggest a role for the environment in shaping the properties of CMM.     

Subjective versus objective sleep outcomes in older adults with and without uncoupled sleep following online cognitive behavioural therapy for insomnia

Background

Uncoupled sleep is a phenomenon characterised by a disconnect between sleep pattern and sleep complaint. This study examined the impact of uncoupled sleep on dysfunctional sleep beliefs and objective and subjective sleep outcomes in community-dwelling older adults following digitally delivered Cognitive Behavioural Therapy for Insomnia (CBT-I) to assess how these groups respond to CBT-I.

Methods

Objective sleep was measured using wrist actigraphy, subjective sleep quality via sleep diaries and the Pittsburgh Sleep Quality Index (PSQI). Dysfunctional sleep beliefs were assessed by the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16). All measurements were taken prior to and following a 4-week online CBT-I program. Linear mixed model and generalised linear mixed model analyses were conducted to examine objective and subjective sleep onset latency, total sleep time, wake after sleep onset and number of awakenings as well as PSQI and DBAS-16 scores, respectively.

Results

Out of 80 enrolled participants, 62 participants (55 females, 89%; 16 complaining good sleepers, 26 complaining poor sleepers, 11 non-complaining good sleepers, and nine non-complaining poor sleepers) completed the study. CBT-I reduced dysfunctional sleep beliefs across all sleeper classifications. Objective and self-reported changes in sleep parameters were demonstrated in complaining poor sleepers without uncoupled sleep. Complaining good sleepers with uncoupled sleep only reported a decrease in the number of subjective sleep awakenings. There were no changes in sleep outcomes in non-complaining good and non-complaining poor sleepers.

Conclusions

Online CBT-I was effective in improving the sleep outcomes of individuals who had both subjective and objective poor sleep. However, as the online CBT-I reduced dysfunctional sleep beliefs in all sleep groups, further examination of dysfunctional sleep beliefs and whether they mediate the outcomes of digital CBT-I in older adults will need to be conducted.     

Active commuting to school: How far is too far?

Background  

Walking and cycling to school provide a convenient opportunity to incorporate physical activity into an adolescent's daily routine. School proximity to residential homes has been identified as an important determinant of active commuting among children. The purpose of this study is to identify if distance is a barrier to active commuting among adolescents, and if there is a criterion distance above which adolescents choose not to walk or cycle.     

Safety of summer camp for children with chronic and/or life threatening illness.

The purpose of this work was to retrospectively evaluate the medical needs of children with chronic and/or life-threatening illness attending summer camp at Barretstown Gang Camp (Ireland). Data on medical facility visits collected over 28 sessions (2120 children) between 1998 and 2001 were reviewed. Children originated from 20 different European countries. The most common diagnoses were leukaemia, lymphoma, sarcoma and brain tumour. Forty-eight percent of the children required medical care during their stay and 3386 total visits were recorded. The most common cause of medical facility visit was pain, followed by injury (trauma, bruises, burn) and flu/cold symptoms. Only 8 brief hospital transfers were necessary for the 2120 children. This large-scale study confirms the safety of a well-organized medically supervised summer therapeutic recreational program for children with chronic conditions, including children undergoing chemotherapy treatment and factor replacement.