Testing a recovery-oriented nursing communication framework to encourage collaboration and discussion about aggression prevention: A mixed methods study

Recovery-oriented practice is essential in healthcare, yet research exploring methods for integrating recovery-oriented principles in forensic mental health settings is limited. This study involved the co-development, with mental health care nurses and a lived experience expert, and testing of a recovery-oriented script for forensic mental health nurses to use when communicating with consumers at high-risk of imminent aggression. The aim was to examine whether nurses perceived the script as more empathic when the script included specific references to empathy, compared to an equivalent script that did not include empathic statements, and to explore nurses' perspectives on whether the script could help prevent aggression. Nurses (n = 54) working in a secure forensic mental health hospital were randomly allocated to read a script containing statements representing nine recovery-oriented principles that also included empathic statements, or an equivalent script that did not include empathic statements. After reading the script, the participants completed a questionnaire involving a recovery-oriented practice scale developed by the authors, measuring the extent to which the scripts reflected recovery-oriented principles, and open-ended questions about the script's potential to prevent aggression. Results revealed no significant difference in nurse perceptions of empathy between the two scripts. Content analysis indicated that nurses perceived the scripts could help prevent aggression.

Exploring the role of the nurse unit manager in forensic mental health inpatient units: A qualitative study

Forensic mental health (FMH) inpatient settings are complex working environments at times due to a number of factors including the presence of challenging behaviours that may include violence and aggression, restrictions related to legislation, extended length of stay and the impact of trauma. Nurse unit managers (NUMs) play an important role in managing the unit environment and clinical standards of care to achieve better outcomes for consumers and staff. However, the role of NUMs in an FMH setting is poorly understood. The overall aim of this study was to explore the role of NUMs working within an FMH setting in Victoria, Australia. To our knowledge, this is the first study that has examined the subject. Data were collected via focus groups from n = 32 participants which included NUMs, their managers, staff who work alongside the NUMs and the staff the NUMs manage. Data were analysed using thematic analysis and four themes were interpreted from the data, (i) lack of role clarity, (ii) the importance of clinical Leadership and forensic mental health knowledge, (iii) step up in responsibility and step down in pay and (iv) seeing the difference you make. The role of the NUM within a forensic mental health setting comes with a number of challenges, but also opportunities to enact change. An ongoing effort to better support those employed within the NUM role and make the role desirable for aspiring staff is critical to the sustainability of a skilled clinical workforce and quality of care in this complex setting.

Modifying the clinical reasoning cycle to enhance forensic mental health nursing utility

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AIM

The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression).

BACKGROUND

Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions.

METHODS

Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted.

RESULTS

Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice.

CONCLUSIONS

EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Using the Dynamic Appraisal of Situational Aggression (DASA) to assess the impact of unit atmosphere on violence risk assessment

WHAT IS KNOWN ON THE SUBJECT

Research suggests that the Dynamic Appraisal of Situational Aggression (DASA) is a useful risk assessment instrument to identify individuals who might be at risk of aggression in mental health inpatient units. Although, risk assessment research has typically focused on an individual's risk of aggression, recent research has begun exploring whether the DASA could be used to assess the likelihood that a group of patients would be aggressive.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

While the DASA was useful for assessing whether an individual was likely to be aggressive, the group average score was not a useful indicator for the likelihood of aggression once the individual DASA score was taken into consideration. Unexpectedly, patients who were assessed as high risk on the DASA were more likely to be aggressive on settled units compared to unsettled units, which included other individuals whose risk was elevated.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

There is not enough evidence to suggest that the group DASA average improves the identification of aggression above the individual DASA score.

ABSTRACT

INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is an inpatient aggression risk assessment instrument. Recently, research explored whether the unit atmosphere, as indicated by a unit's average DASA score, was related to inpatient aggression risk, but failed to control for individual risk.

AIM

Investigate whether the DASA unit average score or an interaction between the unit average and an individual patient's DASA score was related to the likelihood that an individual would act aggressively.

METHOD

Cox regression with repeated assessments and recurrent events was used to analyse 11,243 DASA risk assessments of 113 inpatients collected via retrospective file review.

RESULTS

The unit DASA average score was not related to aggression towards staff. There was a negative interaction between the individual and the unit DASA average scores when identifying patient-to-patient aggression; high-risk patients engaged in less aggression when the unit average was heightened relative to units with lower DASA average scores.

DISCUSSION

It is possible that there were more nursing interventions and/or patients engaged in greater self-regulation on unsettled units, thus reducing aggression.

IMPLICATIONS FOR PRACTICE

Currently, there is insufficient evidence to suggest that the unit average score should be used to supplement individual DASA scores to identify aggression risk.

Exploring adaptations to the clinical reasoning cycle for forensic mental health nursing: A qualitative enquiry

Forensic mental health nurses (FMHN) provide care to address the needs of people who have mental illnesses across a range of diverse settings. The Clinical Reasoning Cycle (CRC) has been identified as a potential framework to assist FMHNs; however, adaptations were required to reflect the unique nature of the clinical setting. This study aimed to explore adaptations made to determine suitability prior to implementation in practice. Nominal Group Technique was used to explore suggested adaptations determined from a previous study and reach a consensus on the changes. Fourteen senior nurses from a state-wide Forensic mental Health (FMH) service participated. A consensus was reached for two proposed changes. Data were analysed using thematic analysis. Three main themes were interpreted from the data; FMH adaptations are warranted, the focus of the CRC, and who owns the cycle? Nurses in this study considered the need to include offence and risk issues due to the impact these factors have on the therapeutic relationship and cognitive bias; however, they also identified the need to focus on recovery-oriented care while engaging in clinical reasoning. Nurses in this study also expressed some reluctance for nursing to 'own' the model, due to concern that ownership may cause division among the team or result in inconsistency in care. However, some participant's suggested the CRC with adaptations assisted FMH nurses to articulate their specialist skills and knowledge to others and highlight the nursing contribution to care. Further work is needed to finalize adaptations with a focus on engaging the consumer carer workforce and interdisciplinary team.

Using the Nominal Group Technique to determine a nursing framework for a forensic mental health service: A discussion paper

The Nominal Group Technique is a method used to explore issues, generate ideas, and reach consensus on a topic. The Nominal Group Technique includes individual and group work and is designed to ensure participants have the same opportunity to engage and provide their opinions. While the technique has been used for around six decades to assist groups, in industry, and government organizations to examine issues and make decisions, this technique has received limited attention in nursing research, particularly in mental health. This discussion paper describes the use of a modified Nominal Group Technique for a study designed to determine a nursing decision-making framework for a state-wide forensic mental health service. Modifications were made to the traditional technique, to enable participants to make an informed and collective decision about a suitable framework for the novice to expert nurses, across secure inpatient, prison, and community forensic mental health settings. The Nominal Group Technique generated rich data and offered a structured approach to the process. We argue that the Nominal Group Technique offers an exciting and interactive method for nursing research and can increase opportunity for minority group members to participate. This technique also offers a time efficient way to engage busy clinical nurses to participate in research, with the advantage of members knowing the decision on the day of the group. Consideration, however, needs to be given to the duration and effect on participant concentration, and if not actively managed by facilitators, the possible emergence of group dynamics affecting individuals' decisions.

Safewards Secure: A Delphi study to develop an addition to the Safewards model for forensic mental health services

WHAT IS KNOWN ON THE SUBJECT?: The Safewards model has been introduced to forensic mental health wards with mixed results. Research has identified a need to consider the addition of factors that may be relevant to forensic mental health services to enhance the introduction of Safewards. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study elicits factors specific to forensic mental health settings missing from the original Safewards model, which have the potential to enhance nursing care, improve safety and improve adherence to Safewards in a forensic mental health setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study provides the adaptation required in a forensic mental health setting to enhance the implementation of the Safewards model of care, originally developed to assist nurses to prevent and manage conflict and containment in acute general mental health settings. The development of Safewards Secure has incorporated perspectives from expert Safewards and forensic mental health nurse leaders and healthcare clinicians and is inclusive of consumer and carer perspectives to ensure the model is applicable and broadly acceptable. ABSTRACT: Introduction Safewards is a model designed specifically for acute mental inpatient wards. Research investigating the introduction of Safewards has identified a need to consider factors relevant in forensic mental health services, such as offence and risk issues. Aim To identify adaptations needed to address gaps in the Safewards model to assist forensic mental health nurses to prevent and manage conflict and containment. Method A Delphi study was employed to engage a group of international Safewards and forensic mental health experts (n = 19), to elucidate adaptation of the Safewards model. Results Experts identified necessary elements and reached consensus on key considerations for Safewards interventions. To ensure the Safewards Secure model was robust and developed on a platform of research, all items suggested by Delphi experts were cross-referenced and dependent on empirical evidence in the literature. Discussion This study identified a number of key differences between civil and forensic mental health services, which informed the development of Safewards Secure, an adjunct to the original Safewards model. Implications for Practice The development of person-centred models of nursing care adapted to specific settings, such as forensic mental health, provides a potential solution to preventing and managing conflict and containment, and improving consumer outcomes. Relevance Statement Managing conflict and containment in mental health services remains an ongoing challenge for mental health nurses. Safewards is a model of care designed for acute mental health inpatient settings to prevent conflict and containment. To date, there has been mixed results when introducing Safewards in forensic mental health settings, and reported reluctance and scepticism. To address these issues, this study employed a Delphi design to elicit possible adaptions to the original Safewards model. From this study, Safewards Secure was developed with adaptations designed for forensic services, to enhance the management of conflict and containment, assist implementation and improve consumer outcomes.

Exploration of the utility of the Nursing Process and the Clinical Reasoning Cycle as a framework for forensic mental health nurses: A qualitative study

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce.

The Model for Understanding Inpatient Aggression: A Version for Mental Health Nurses Working in Prisons

Preventing and managing aggression remains an important and challenging task for mental health nurses. Despite the concern, there is a dearth of frameworks to assist practice and inform assessment and intervention related to aggression, for forensic mental health nurses working in prisons. This paper presents a model for understanding aggression within prison mental health units. The model elucidates various personal and situational determinants of aggression. It offers a systematic framework for mental health nurses to investigate and understand aggression, to ultimately assist nurses to provide care in an informed and effective manner, and for services to consider structural factors that contribute to the risk of aggression.

Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study

OBJECTIVES

Forensic mental health services (FMHS) have higher rates, duration and frequency of restrictive practices (seclusion, physical restraint and mechanical restraint). Data generated by services can be used to set targets (benchmarks) with like services to reduce or eliminate restrictive practices. The aim of this study was to develop restrictive practice benchmarks for Australian and New Zealand FMHS.

METHOD

A participatory action research methodology was used by conducting a Delphi study. FMHS experts provided de-identified service-specific restrictive practice data, which was used to stimulate reflection towards the development of restrictive practice benchmarks.

RESULTS

Consensus decision-making was reached on benchmarks for the rate, duration and frequency of seclusion and physical restraint. Mechanical restraint was found to be a rare event, requiring event specific review in each service.

CONCLUSIONS

Benchmarking with FMHS may assist in working to reduce restrictive practices and encourage the scrutiny of service practice. Establishment of a FMHS network might assist to embed the proposed benchmarks.

A Clinical Decision Support System to Prevent Aggression and Reduce Restrictive Practices in a Forensic Mental Health Service

OBJECTIVE

Preventing aggression and reducing restrictive practices in mental health units rely on routine, accurate risk assessment accompanied by appropriate and timely intervention. The authors studied the use of an electronic clinical decision support system that combines two elements, the Dynamic Appraisal of Situational Aggression instrument and an aggression prevention protocol (eDASA+APP), in acute forensic mental health units for men.

METHODS

The authors conducted a cluster-randomized controlled trial incorporating a crossover design with baseline, intervention, and washout periods in a statewide, secure forensic mental health service. The study included 36 mental health nurses (13 men and 23 women, ages 20-65 years) with direct patient care responsibility and 77 male patients (ages 21-77 years) admitted to one of two acute mental health units during the baseline and intervention periods.

RESULTS

eDASA+APP implementation was associated with a significant reduction in the odds of an aggressive incident (OR=0.56, 95% confidence interval [95% CI]=0.45-0.70, p<0.001) and a significant decrease in the odds of administration of as-needed medication (OR=0.64, 95% CI=0.50-0.83, p<0.001). Physical aggression was too infrequent for statistical significance of any effects of eDASA+APP to be determined; however, incidents of physical aggression tended to be fewer during the eDASA+APP phase.

CONCLUSIONS

These results support the use of the eDASA+APP to help reduce incidents of aggression and restrictive practices in mental health units.

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.

Do recovery outcome measures improve clinical practice? A linguistic analysis of the impact of the Hope, Agency and Opportunity measure in community mental health teams

AIMS

Recovery approaches are identified as the overarching framework for improving mental health services for people with severe and enduring conditions. These approaches prioritise living well with long-term conditions, as evidenced by personal recovery outcomes. There is little research demonstrating how to support busy mental health teams, work in this way. This study assessed the impact of introducing a brief measure of recovery, the Hope, Agency and Opportunity (HAO), on the attitudes and behaviours of staff working in community mental health teams, to test whether routine use of such measures facilitates recovery-based practice.

METHODS

Linguistic analysis assumes that language is indicative of wider attitudes and behaviours. Anonymised clinical notes recorded by community mental health team clinicians were analysed for recovery and non-recovery language, over 30 months. This covered periods before, during and after the introduction of the recovery measure. We used a single-case design (N = 1 community mental health team) and hypothesised that clinicians would use recovery-focused language more frequently, and non-recovery-focused language less frequently, following the introduction of the measure, and that these changes would be maintained at 18-month follow-up.

RESULTS

Visual inspection of the data indicated that recovery-focused language increased following the introduction of the HAO, though this was not maintained at follow-up. This pattern was not supported by statistical analyses. No clear pattern of change was found for non-recovery-focused language.

CONCLUSIONS

The introduction of a brief measure of recovery may have influenced staff attitudes and behaviours temporarily. Any longer term impact is likely to depend on ongoing commitment to the use of the measure, without which staff language, attitudes and behaviours return to previous levels.

Detection of Estrogen Receptor-Beta mRNA in Breast Cancer Using RT-PCR

The estrogen receptor (ER) is the most useful marker currently available for breast cancer, being used both to predict response to therapy and assess prognosis. Recently, a new form of the ER, known as ER-beta, was identified. In this preliminary study we show that ER-beta mRNA was expressed less frequently in breast cancers than ER-alpha. ER-alpha but not ER-beta levels correlated with ER protein as determined by ELISA. We conclude that ER-beta is expressed in approximately 50% of breast cancers but it does not appear to be detected by a widely available ELISA.

Evaluating the Introduction of the Safewards Model to a Medium- to Long-Term Forensic Mental Health Ward

Care and treatment in forensic mental health wards can present with challenges when loss of hope and freedom, and aggression are present, which can then influence ward atmosphere and feelings of safety. Safewards is a model designed to address a range of conflict (e.g., aggression and self-harm) and containment (e.g., use of restrictive interventions) events and may provide a suitable approach to delivery of care in a forensic setting, while also addressing aggression, restrictive interventions, and ward atmosphere. The aim of this study was to evaluate the introduction of Safewards to a forensic mental health ward to determine suitability, and to explore if changes to conflict, containment, and ward atmosphere occurred. A mixed methods approach was used involving the collection of incident data related to conflict and containment, an assessment of the degree to which interventions were implemented, and an assessment of the social climate before and after implementation. Results suggested that there were fewer conflict events after Safewards was introduced; however, there did not appear to be any changes in the already low use of restrictive interventions. The Safewards interventions were implemented to a high degree of fidelity, and there was indication of an increase in a positive perception of ward atmosphere, supported by themes of positive change, enhanced safety, and respectful relationships. Safewards may assist in contributing to an improvement in the perception of ward atmosphere. To enhance implementation in a forensic mental health setting, there may be a need to consider additional elements to Safewards, pertinent to this setting.

Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study

Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8 hours) and mechanical restraint (>1 hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann-Whitney U-tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n = 320, 46%) involved mechanical restraint. Seclusion episodes (n = 370) were longer in forensic mental health services compared to adult area mental health services (median: 24 hours and 18 min vs 16 hours and 42 min, P < 0.001). Mechanical restraint episodes (n = 320) were shorter in forensic mental health services compared to adult area mental health services (median: 3 hours and 25 min vs 4 hours and 15 min, P = 0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was 'risk of harm to others'. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings.

Predicting aggressive behaviour in acute forensic mental health units: A re-examination of the dynamic appraisal of situational aggression's predictive validity

In the present study, we explored the predictive validity of the Dynamic Appraisal of Situational Aggression (DASA) assessment tool in male (n = 30) and female (n = 30) patients admitted to the acute units of a forensic mental health hospital. We also tested the psychometric properties of the original DASA bands and novel risk bands. The first 60 days of each patient's file was reviewed to identify daily DASA scores and subsequent risk-related nursing interventions and aggressive behaviour within the following 24 hours. Risk assessments, followed by documented nursing interventions, were removed to preserve the integrity of the risk-assessment analysis. Receiver-operator characteristics were used to test the predictive accuracy of the DASA, and generalized estimating equations (GEE) were used to account for repeated risk assessments, which occurs when analysing short-term risk-assessment data. The results revealed modest predictive validity for males and females. GEE analyses suggested the need to adjust the DASA risk bands to the following (with associated odds ratios (OR) for aggressive behaviour): 0 = low risk; 1, 2, 3 = moderate-risk OR, 4.70 (95% confidence interval (CI): 2.84-7.80); and 4, 5, 6, 7 = high-risk OR, 16.13 (95% CI: 9.71-26.78). The adjusted DASA risk bands could assist nurses by prompting violence-prevention interventions when the level of risk is elevated.

Association of methamphetamine use and restrictive interventions in an acute adult inpatient mental health unit: A retrospective cohort study

The aim of the present study was to describe incidences of restrictive interventions and the association of methamphetamine use at an acute adult inpatient mental health unit in metropolitan Melbourne, Victoria, Australia. A total of 232 consecutive consumer admissions to the inpatient unit across a 3-month period were described for illicit substance use and the use of restrictive interventions (seclusion, mechanical restraint, and physical restraint) prior to and during admission. Of all admissions, 25 (10.8%) involved consumers subjected to a restrictive intervention. Methamphetamine use was either self-reported or detected by saliva test for 71 (30.6%) consumers. Following multivariate analyses, methamphetamine use (odds ratio (OR): 7.83, 95% confidence interval (CI): 2.33-26.31) and restrictive intervention in the emergency department prior to admission (OR: 8.85, 95% CI: 2.83-27.70) were significant independent predictors of the use of restrictive interventions after inpatient admission. Anecdotal observations provided by clinical mental health staff that consumers intoxicated with methamphetamine appear to require restrictive intervention more frequently than other consumers was confirmed with the results of the current study. As the state of Victoria in Australia is on a pathway to the elimination of the use of restrictive interventions in mental health services, clinicians need to develop management strategies that provide specialist mental health care using the least-restrictive interventions. Although 26.8% of methamphetamine users were secluded after admission, restrictive interventions should not be the default management strategy for consumers who present with self-report or positive screen for methamphetamine use.

Control Release Anesthetics to Enable an Integrated Anesthetic-mesenchymal Stromal Cell Therapeutic

While general anesthetics control pain via consciousness regulation, local anesthetics (LAs) act by decreasing sensation in the localized area of administration by blocking nerve transmission to pain centers. Perioperative intra-articular administration of LAs is a commonly employed practice in orthopedic procedures to minimize patient surgical and post-surgical pain and discomfort. LAs are also co-administered with cellular mesenchymal stromal cell (MSC) therapies for a variety of tissue regenerative and inflammatory applications including osteoarthritis (OA) treatment; however, LAs can affect MSC viability and function. Therefore, finding an improved method to co-administer LAs with cells has become critically important. We have developed a sustained release LA delivery model that could enable the co-administration of LAs and MSCs. Encapsulation of liposomes within an alginate matrix leads to sustained release of bupivacaine as compared to bupivacaine-containing liposomes alone. Furthermore, drug release is maintained for a minimum of 4 days and the alginate-liposome capsules mitigated the adverse effects of bupivacaine on MSC viability.

Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study

BACKGROUND

Practicing with trauma informed care (TIC) can strengthen nurses' knowledge about the association of past trauma and the impact of trauma on the patient's current mental illness. An aim of TIC is to avoid potentially re-traumatising a patient during their episode of care. A TIC education package can provide nurses with content that describes the interplay of neurological, biological, psychological, and social effects of trauma that may reduce the likelihood of re-traumatisation. Although mental health nurses can be TIC leads in multidisciplinary environments, the translation of TIC into clinical practice by nurses working in emergency departments (EDs) is unknown. However, before ED nurses can begin to practice TIC, they must first be provided with meaningful and specific education about TIC. Therefore, the aims of this study were to; (1) evaluate the effectiveness of TIC education for ED nursing staff and (2) describe subsequent clinical practice that was trauma informed.

METHODS

This project was conducted as exploratory research with a mixed methods design. Quantitative data were collected with an 18-item pre-education and post-education questionnaire. Qualitative data were collected with two one-off focus groups conducted at least three-months after the TIC education. Two EDs were involved in the study.

RESULTS

A total of 34 ED nurses participated in the TIC education and 14 ED nurses participated in the focus groups. There was meaningful change (p < 0.01, r ≥ 0.35) in 9 of the 18-items after TIC education. Two themes, each with two sub-themes, were evident in the data. The themes were based on the perceived effectiveness of TIC education and the subsequent changes in clinical practice in the period after TIC education.

CONCLUSION

Emergency department nurses became more informed of the interplay of trauma on an individual's mental health. However, providing care with a TIC framework in an ED setting was a considerable challenge primarily due to time constraints relative to the day-to-day ED environment and rapid turnover of patients with potentially multiple and complex presentations. Despite this, nurses understood the effect of TIC to reduce the likelihood of re-traumatisation and expressed a desire to use a TIC framework.

Exploring nurses' and patients' perspectives of limit setting in a forensic mental health setting

Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced); and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting.

Standards of practice for forensic mental health nurses--identifying contemporary practice

Forensic mental health nursing is a recognized field of nursing in most countries. Despite a growing body of literature describing aspects of practice, no publication has been found that captures the core knowledge, skills, and attitudes of forensic mental health nurses. One group of nurses in Australia have pooled their knowledge of relevant literature and their own clinical experience and have written standards of practice for forensic mental health nursing. This paper identifies the need for standards, provides a summary of the standards of practice for forensic mental health nurses, and concludes with how these standards can be used and can articulate to others the desired and achievable level of performance in the specialty area.

Seclusion reduction in a forensic mental health setting

Seclusion has become a contentious practice and initiatives have commenced to reduce or eliminate its use. This paper presents the initiatives that were introduced during a seclusion reduction project that was undertaken at an Australian forensic hospital. These initiatives are based on the six core strategies that have been successfully used in North America to reduce seclusion. However, there are challenges (patient characteristics, prisoner culture and ensuring safety) and opportunities (longer admissions, higher staff-patient ratio, staff confidence, sound risk assessment and management) that can influence projects to reduce seclusion in a forensic hospital. During this project, the frequency (mainly multiple seclusions of patients) and duration of seclusion events were reduced but there was less reduction in the number of patients that were secluded. It is possible that the strategies were successfully supported by the identified opportunities to reduce the frequency and duration of seclusion but the challenges were significantly powerful in the early period of admission to prompt the need for seclusion. Reducing seclusion in a forensic hospital is a complex undertaking as nurses must provide a safe environment while dealing with volatile patients and may have little alternative at present but to use seclusion after exhausting other interventions.

A report of three patients with MMP2 associated hereditary osteolysis

Osteolysis syndromes are rare hereditary disorders characterized by destruction and resorption of affected bones. The current study adds three new patients from two unrelated consanguineous families with a severe form of inherited osteolysis. Clinical examination, radiological, biochemical, ultrastructural and molecular studies were conducted. Clinical and radiological studies suggested the diagnosis of Torg-Winchester syndrome. The three affected patients were homozygous for novel MMP2 gene mutations which confirmed the diagnosis. Our patients are the first to be reported from Egypt thus, supporting the pan ethnic nature of the disease.

Evaluation of a microfluidic based cell culture platform with primary human hepatocytes for the prediction of hepatic clearance in human

Integral to the discovery of new pharmaceutical entities is the ability to predict in vivo pharmacokinetic parameters from early stage in vitro data generated prior to the onset of clinical testing. Within the pharmaceutical industry, a whole host of assay methods and mathematical models exist to predict the in vivo pharmacokinetic parameters of drug candidates. One of the most important pharmacokinetic properties of new drug candidates predicted from these methods and models is the hepatic clearance. Current methods, while useful, are still limited in their predictive efficacy. In order to address this issue, we have established a novel microfluidic in vitro culture system, the patented HmuREL device. The device comprises multiple compartments that are designed to be proportional to the physiological architectures and enhanced with the consideration of flow. Here we demonstrate the functionality of the liver-relevant chamber in the HmuREL device, and the feasibility of utilizing our system for predicting hepatic clearance. Cryopreserved human hepatocytes from a single donor were seeded within the HmuREL device to predict the in vivo hepatic clearance (CL(H)) of six marketed model compounds (carbamazepine, caffeine, timolol, sildenafil, imipramine, and buspirone). The intrinsic clearance rates from static culture controls, as well as clearance rates from the HmuREL device were subsequently compared to in vivo data available from the literature.

High levels of TIMP-2 correlate with adverse prognosis in breast cancer

TIMP-2 is an endogenous inhibitor of MMPs. Most data from model systems suggest that high levels of this inhibitor prevent metastasis. In human breast cancers, however, we show that high levels of TIMP-2 correlate with both shortened disease-free interval and overall survival. In primary breast cancers, TIMP-2 levels showed no significant relationship with either tumor size or axillary node status but correlated inversely with estrogen receptor levels. TIMP-2 levels also correlated significantly with those for TIMP-1. We conclude that high levels of endogenous TIMP-2, like other protease inhibitors such as PAI-1 and TIMP-1, correlate with progression of human breast cancer.

Low levels of urokinase plasminogen activator components in basal cell carcinoma of the skin

Basal cell carcinoma of the skin (BCC) is the most common cancer worldwide. Unlike most other human malignancies, BCCs rarely metastasise. In this investigation, we show that the serine protease urokinase plasminogen activator (u-PA), which is causally involved in metastasis, is expressed at lower levels in BCCs compared to other skin cancers, such as squamous-cell carcinomas (SCCs) or malignant melanomas. Similarly, the u-PA receptor as well as the inhibitor PAI-1 were present at lower levels in BCCs relative to both SCCs and melanomas. In contrast to u-PA, tissue-plasminogen activator, which is not thought to be involved in metastasis, was present at similar levels in the different types of skin lesion investigated. We conclude that the failure of BCCs to metastasise may at least be partially related to low expression of components of the u-PA system.

High levels of tissue inhibitor of metalloproteinase-1 predict poor outcome in patients with breast cancer

Studies from model systems suggest that matrix metalloproteinases (MMPs) are causally involved in tumor progression while tissue inhibitors of MMPs (TIMPs) prevent this progression. Here, we show that concentrations of TIMP-1 are significantly higher in breast carcinomas than in fibroadenomas. In primary breast cancers, TIMP-1 concentrations increased with increasing tumor size but showed an inverse relationship with estrogen receptor concentrations. In primary breast cancers also, TIMP-1 levels were weakly but significantly correlated with those for MMP-1, proMMP-2, active MMP-2, MMP-3 and proMMP-9. Contrary to what might be expected from published data on model systems, high concentrations of TIMP-1 predicted a poor outcome in patients with breast cancer. We conclude that in human breast cancer, endogenous TIMP-1 does not inhibit tumor progression but may enhance the process.

High levels of tissue inhibitor of metalloproteinase-1 predict poor outcome in patients with breast cancer

Studies from model systems suggest that matrix metalloproteinases (MMPs) are causally involved in tumor progression while tissue inhibitors of MMPs (TIMPs) prevent this progression. Here, we show that concentrations of TIMP-1 are significantly higher in breast carcinomas than in fibroadenomas. In primary breast cancers, TIMP-1 concentrations increased with increasing tumor size but showed an inverse relationship with estrogen receptor concentrations. In primary breast cancers also, TIMP-1 levels were weakly but significantly correlated with those for MMP-1, proMMP-2, active MMP-2, MMP-3 and proMMP-9. Contrary to what might be expected from published data on model systems, high concentrations of TIMP-1 predicted a poor outcome in patients with breast cancer. We conclude that in human breast cancer, endogenous TIMP-1 does not inhibit tumor progression but may enhance the process.

Progressive maturation resistance to microcystin-LR cytotoxicity in two different hepatospheroidal models

To develop three-dimensional (3D) cytotoxicity models further, microcystin-induced cytoskeletal disruption was tested in two different models of multicellular hepatocyte aggregate formation (hepatospheroids). Rat hepatocyte suspensions were seeded either onto poly(2-hydroxyethylmethacrylate)-treated culture wells (poly-HEMA) or in a rotating wall vessel (RWV) device which provides minimal shear forces and enhances differentiated 3D growth. Ninety percent of spheroids forming on poly-HEMA tended to fuse and form nonhomogeneous multilobular structures by day 4 of incubation. In contrast, spheroids cultured in the low-shear environment formed homogeneous aggregates that averaged 126 + 10 microm diameter in size at day 7. Microcystin-LR (10(-6) mol/L) was put into contact (90 min in serum-free medium) with hepatocyte suspensions and spheroids formed in both systems for 1, 4 or 7 days. As already described, microcystin-LR (after 90 min), induced cytoskeletal disruptions (blebs) in 98% of the isolated primary hepatocytes maintained in suspension. In 3D cultures, blebs were detected only on poly-HEMA nonhomogeneous early prespheroids. All other mature spheroids (poly-HEMA or RWV) exposed to the toxin did not exhibit obvious morphological signs of toxicity. Moreover, microcystin-LR pre-incubation with hepatocyte suspension prevented the formation of conventional spheroids. In conclusion, the low-shear, simulated-microgravity environment generated high yields of regularly engineered spheroids. In both models, progressive resistance of mature spheroids to microcystin-LR-induced cell deformation developed with time in culture. Microcystin-LR inhibition of the formation of rat hepatospheroids in isolated hepatocyte suspension could be used as a complementary biological assay for detection of the presence of biologically active microcystin-LR in water samples.

Dengue virus infectivity depends on envelope protein binding to target cell heparan sulfate

Dengue virus is a human pathogen that has reemerged as an increasingly important public health threat. We found that the cellular receptor utilized by dengue envelope protein to bind to target cells is a highly sulfated type of heparan sulfate. Heparin, highly sulfated heparan sulfate, and the polysulfonate pharmaceutical Suramin effectively prevented dengue virus infection of target cells, indicating that the envelope protein-target cell receptor interaction is a critical determinant of infectivity. The dengue envelope protein sequence includes two putative glycosaminoglycan-binding motifs at the carboxy terminus; the first could be structurally modeled and formed an unusual extended binding surface of basic amino acids. Similar motifs were also identified in the envelope proteins of other flaviviridae. Developing pharmaceuticals that inhibit target cell binding may be an effective strategy for treating flavivirus infections.

Demonstration of binding of dengue virus envelope protein to target cells

The nature of the initial interaction of dengue virus with target cells and the extent to which this interaction defines tropism are unknown. Infection of some cells may involve antidengue antibody-mediated immune adherence to cells bearing immunoglobulin Fc receptors; however, this mechanism does not explain primary infection or the infection of cells without Fc receptors. We hypothesized that dengue virus envelope protein mediates initial binding to target cells. To test this hypothesis, a recombinant chimeric form of dengue type 2 virus envelope protein was used as a probe to investigate binding to the surfaces of potential target cells. Envelope protein was expressed amino terminal to the heavy-chain constant region of human immunoglobulin G containing the Fc receptor binding motif; the binding mediated by envelope determinants was distinguishable from the binding mediated by immunoglobulin Fc determinants. We found that the recombinant chimera bound to Vero, CHO, endothelial, and glial cells through envelope protein determinants and to monocytes and U937 cells by Fc-Fc receptor interactions. The highest level of binding was to Vero cells; binding was dose and time dependent and saturable. Examination of partial-length recombinant envelope proteins indicated that the binding motif was expressed between amino acids 281 and 423. Recombinant envelope protein inhibited infection of Vero cells by dengue virus, indicating the functional significance of the interaction of envelope protein and target cells in infectivity. These results suggest that envelope protein binding to a non-Fc receptor could explain the cell and tissue tropism of primary dengue virus infection.

Does volume of clinical experience affect performance of clinical clerks on surgery exit examinations?

BACKGROUND

Controversy persists over the educational value of student clerkship clinical activities.

METHODS

Students (109) from the class of 1995 recorded their clinical experiences in a logbook during their surgical clerkship at one of four affiliated teaching hospitals. The influence of clinical experience on examination scores and on correlations between prerotation and postrotation examination performance was determined.

RESULTS

Between sites, marked variation in clinical experience was observed but postrotation scores were similar. High-volume experience in emergency admissions and feedback was associated with better objective structured clinical examination (OSCE) performance, but high-volume outpatient clinic experience was associated with less satisfactory OSCE performance. Correlations between prerotation examination performance and the OSCE was increased by feedback on emergency and elective admissions, in a positive and negative direction, respectively.

CONCLUSIONS

These data show that surgical clerks' clinical skills were enhanced by an increased volume of some but not all clinical experiences and that feedback does not necessarily enhance performance. These data suggest that both the volume of clinical experience and the quality of feedback should be carefully monitored by surgical clerkship directors.

Urokinase plasminogen activator as a predictor of aggressive disease in breast cancer

Urokinase plasminogen activator (uPA) is a multifunctional protein involved in both extracellular proteolysis and signal transduction. uPA usually mediates its actions while attached to a membrane-bound receptor, termed uPAR. In this study, uPA and its receptor were measured at both protein and mRNA levels in breast cancer. At both levels, concentrations of uPA were significantly correlated with those for uPAR. uPA levels also correlated significantly with cathepsin B and cathepsin D but not with cathepsin L, MMP-8 or MMP-9 levels. Irrespective of the cut-off point used (e.g., median, tertile or quartile values), uPA was a significant prognostic marker for breast cancer.

Urokinase plasminogen activator and urokinase plasminogen activator receptor in breast cancer

Urokinase plasminogen activator (uPA) is a serine protease involved in cancer invasion and metastasis. uPA mediates its action while attached to a membrane-bound receptor (uPAR). In this investigation we show that uPAR levels correlate with uPA levels in human breast cancers. uPAR levels, however, do not correlate with other components of the plasminogen activator system such as tissue-type plasminogen activator (t-PA), PAI-I or PAI-2. In addition, uPAR levels showed no correlation with tumor size, axillary-node status or estrogen-receptor status. On the basis of an optimum cut-off point, patients with breast cancers containing high levels of uPAR had a worse prognosis than patients with low levels of the receptor. However, as a prognostic marker in breast cancer, uPAR was not as strong as uPA. Our results are consistent with data from model systems suggesting that both uPA and uPAR are necessary for metastasis.

Problem-based learning: its role in undergraduate surgical education

OBJECTIVE

To familiarize the surgeon with problem-based learning (PBL) and to discuss the current and future role of PBL in undergraduate surgical education.

DATA SOURCES

Two meta-analyses comparing the outcome of a PBL curriculum with a traditional curriculum and other studies in the English-language literature.

STUDY SELECTION

Data on the effectiveness of PBL can best be assessed by a meta-analysis in which the conclusions of many studies are reviewed and combined to provide a more comprehensive picture. The studies chosen represent those from the only two recent meta-analyses of the problem that have appeared in reputable journals.

DATA EXTRACTION

Results reported are those obtained using appropriate techniques and published in reputable journals. Information relevant to the major issues in undergraduate surgical training was selected for inclusion.

DATA SYNTHESIS

PBL depends on self-directed learning, triggered by a clinical problem. The students meet in small groups led by a facilitator and discuss carefully designed clinical cases. At the conclusion, the students will have encountered all the information necessary to solve the case and, in so doing, will have gained knowledge that in a conventional curriculum would usually have been disseminated by lecture. There were only small differences between graduates from the two types of curricula. Those from a PBL curriculum had comparable examination results to those from a traditional curriculum on both basic science and clinically based examinations but were happier with their educational experiences.

CONCLUSIONS

Centres that have adopted a PBL approach have found improved student motivation and enjoyment, but there has been no convincing evidence of improved learning. An intelligent combination of both traditional and PBL approaches will likely provide the most effective training for undergraduate surgical clerks.