A Survey of Stress and Burnout in Forensic Mental Health Nursing

BACKGROUND

Although it is known that forensic mental health nurses (FMHNs) work in a stressful environment, their experience of stress and burnout remains largely unexplored.

AIM

The study aimed to measure levels of burnout and workplace stressors experienced by FMHNs.

METHODS

A survey of 205 FMHNs was undertaken. Respondents completed the Maslach Burnout Inventory and the Nursing Stress Scale.

FINDINGS

Fifty-seven FMHNs completed the survey, representing a response rate of 27.8%. Only five respondents (8.8%) experienced high levels of burnout across all three Maslach Burnout Inventory subscales. The most reported workplace stressors were related to "workload," "conflict with other nurses," and "conflict with physicians." A correlation between total Nursing Stress Scale score and both "emotional exhaustion" and "cynicism" were found (r = 0.45, p < 0.001, and r = 0.34, p < 0.011, respectively), indicating that FMHNs who reported higher workplace stress are at an increased risk of burnout.

CONCLUSION

Most FMHNs in the current study experienced moderate levels of burnout, although they continued to feel self-assured in their practice and found their work rewarding. Consistent with other nursing populations, the FMHNs in this study reported feeling stressed by their workload and as the result of conflict with other nurses and physicians.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

Reduced well-being, associated with stress and burnout, may lead to increased absences from work and the delivery of poor-quality forensic mental health consumer care. The implementation of staff well-being strategies is recommended to address stress and burnout in FMHNs.

Evaluation of a totally smoke-free forensic psychiatry in-patient facility: practice and policy implications

Objective To evaluate the impact of implementing a smoke-free policy in an Australian high-security forensic psychiatry in-patient hospital. Methods Focus groups (n = 21) and surveys with both patients (n = 45) and staff (n = 111; 53.2% nurses) elicited participants’ experience of and attitudes towards an introduced smoke-free policy. A follow-up survey elicited the impact of the policy on 15 patients’ smoking practice after discharge. Results Eighty-five per cent of patients stated it was easier to quit smoking when no one else smoked. Over half the discharged patients surveyed (58%) continued to not smoke after discharge, despite almost half the staff (41%) perceiving that patients were unlikely to quit long-term. Smoking staff were significantly more pessimistic than non-smoking staff. Many patients (69%) perceived that their health had improved as a result of not smoking. Most staff (80%) viewed nicotine dependence treatment as important, but fewer (66%) felt confident to support patients to stop smoking. Increased patient violence and management difficulties expected by staff were not realised. Conclusions A smoke-free policy can be successfully implemented in forensic psychiatry in-patient units. Nursing staff are a large and important group who need particular support to implement a smoke-free policy into practice effectively, particularly those who are smokers. Continuity of care as part of a coordinated policy and service response is needed. What is known about the topic? Healthcare settings are increasingly going totally smoke free, with mental health facilities the slowest to implement these policy changes. This is due, in part, to the fear of possible increases in violence and aggression among a patient population who have a high prevalence of smoking. What does this paper add? This paper adds to the evidence base that implementing a smoke-free policy in mental health in-patient hospitals is not only feasible, but also has substantial benefits for both staff and patients. In particular, it highlights the policy and practice implications that can assist mental health facilities to go smoke free. What are the implications for practitioners? A smoke-free policy can be successfully implemented in forensic psychiatry in-patient units; however, more support and education for staff is needed to increase their confidence and capacity to implement the policy consistently across service domains.

Skeletal and hormonal responses to vitamin D supplementation during sunlight deprivation in Antarctic expeditioners

Sunlight deprivation results in vitamin D deficiency but serum vitamin D levels can be maintained above 50 nmol/L when supplemented with 50,000 IU at least every alternate month.

INTRODUCTION

Antarctic expeditioners are exposed to prolonged sunlight deprivation resulting in vitamin D deficiency. We hypothesised that monthly dosing of 50,000 IU vitamin D (~1,600 IU daily) will increase serum 25-hydroxyvitamin D (25(OH)D), suppress parathyroid hormone (PTH) and improve bone mineral density (BMD), 50,000 IU alternate months (~800 IU daily) will maintain these measures, while a single 50,000 IU dose pre-departure (~1,00 IU daily) will not be protective.

METHODS

This was a randomised double-blind study involving 110 healthy adults: 91 males, mean age 41 years (range 24-65 years) working in Antarctica for up to 12 months, who we administered 50,000 IU vitamin D3 monthly, alternate months or a single dose pre-departure. Serum 25(OH)D, PTH, osteocalcin, CTx and calcium were assessed at baseline, mid- and end of expedition. Proximal femur and lumbar spine BMD were assessed pre- and post-expedition.

RESULTS

Baseline 25(OH)D was 59 ± 14 nmol/L. By mid-expedition, 25(OH)D increased by 7 nmol/L in those supplemented monthly (p < 0.05) and remained unchanged in those supplemented in alternate months. In those given a single dose pre-departure, 25(OH)D decreased by 8 nmol/L (p < 0.05) and PTH increased by 27% (p < 0.09). Serum osteocalcin increased by ~22% in all groups but BMD remained unchanged. If serum 25(OH)D was >50 nmol/L at baseline, 25(OH)D was maintained above this level with all regimens. If 25(OH)D was <50 nmol/L at baseline, monthly or alternate month regimens were needed to achieve levels >50 nmol/L, the single pre-departure dose was ineffective.

CONCLUSION

During sunlight deprivation of up to 12 months, serum 25(OH)D levels can be maintained above 50 nmol/L when expeditioners are provided with 50,000 I U at least every alternate month.

Neurological disorders presenting mainly in adolescence

The aim of this review is to discuss some of the neurological diseases that present mainly in the adolescent period. The article focuses on the usual presentation and course of the more common, and some uncommon, epilepsies, neuromuscular disorders, neurodegenerative disorders, inflammatory disorders of the central nervous system and some other, miscellaneous conditions. The article ends with a very brief and general discussion about management issues in this age group.

Hydralazine-demethylating systemic therapy for breast cancer

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Background: Cancer results from accumulation of gene deregulations. DNA sequence alterations are of unquestioned importance in this process, but are not exclusive. Alterations in gene function unaccounted for by DNA sequence changes (Epigenetic) are quite common, and seem to contribute to carcinogenesis. Abnormal methylation at the promoter region of Tumor Suppressor Genes results in gene transcriptional silencing, and is wide spread in many cancers, including Breast Cancer (BC). Alterations in cancer DNA methylation (DNAm) is among the best characterized epigenetic anomalies. An attractive feature of DNAm is its predisposition to pharmacologic reversal as a therapeutic intervention. Here, we used the cardiovascular drug hydralazine (H) to confirm its proposed demethylating effects and to examine its safety in clinically recommended doses concurrent with chemotherapy. Methods: Operable BC patients undergoing neoadjuvant therapy were enrolled on this study (n = 13). We examined DNAm levels at 2 time points; untreated tumor (biopsy) and H-treated specimen (resection) from the same patient. Global DNAm levels were estimated by examining the methylation level in Alu repeats. The study design conformed to a phase I, dose escalating scheme. H was administered at 50 mg orally TID for the first cohort in addition to standard chemotherapy. Results: H was well tolerated to a maximal dose of 200 mg QID. 1 patient discontinued the drug for headache. 4 patients completed treatment (approx. 4 months) and underwent surgical resection and assessment of methylation. Global Demethylation (defined as decrease of Alu methylation level by ≥5%) was observed in 2/4 [−8% and −9%, respectively]. The remaining patients have undergone surgery but DNA testing not performed as yet (results will be presented in the meeting). Conclusions: Hydralazine is well tolerated in normotensive individuals, in doses ≤ 200 mg/d concurrently with standard chemotherapy for breast cancer. Further, hydralazine produces decrement in DNAm of clinical cancer specimens. Effect of this demethylation on the expression of biologically important genes such as ER and p16 will be evaluated and presented once available. The biologic effect of such alteration in genomic DNAm would require subsequent investigation to prove its therapeutic impact.

No significant financial relationships to disclose.

Serious neurological disorders in children with chronic headache

AIMS

To determine the prevalence of serious neurological disorders among children with chronic headache.

METHODS

All children presenting to a specialist headache clinic over seven years with headache as their main complaint were assessed by clinical history, physical and neurological examination, neuroimaging where indicated, and by follow up using prospective headache diaries.

RESULTS

A total of 815 children and adolescents (1.25-18.75 years of age, mean 10.8 years (SD 2.9); 432 male) were assessed. Mean duration of headache was 21.2 months (SD 21.2). Neuroimaging (brain CT or MRI) was carried out on 142 (17.5%) children. The vast majority of patients had idiopathic headache (migraine, tension, or unclassified headaches). Fifty one children (6.3%) had other chronic neurological disorders that were unrelated to the headache. The headache in three children (0.37%, 95% CI 0.08% to 1.1%) was related to active intracranial pathology which was predictable on clinical findings in two children but was unexpected until a later stage in one child (0.12%, 95% CI 0.006% to 0.68%).

CONCLUSIONS

Chronic headache in childhood is rarely due to serious intracranial pathology. Careful history and thorough clinical examination will identify most patients with serious underlying brain abnormalities. Change in headache symptomatology or personality change should lower the threshold for imaging.

Nasal/buccal midazolam use in the community

A telephone survey was carried out to evaluate the effectiveness and convenience of nasal/buccal midazolam in terminating prolonged seizures in the community. A total of 33/40 (83%) families who had used it found it effective and easy to use; 20/24 (83%) preferred using midazolam to rectal diazepam.

Fish hook injury to the eyelid - an unusual case

Fishing is recreational activity enjoyed by millions of people worldwide. Although uncommon in developing countries it is a popular pastime in the Western world. and, given this popularity, a number of associated personal injuries are probably inevitable. We report a case of fish hook injury to the eyelid and discuss the various techniques available for removal of fish hooks. The terminologies associated with various parts of the fish hook are also illustrated.

Qualitative and quantitative strategies of thermal adaptation of grass carp (Ctenopharyngodon idella) cytoplasmic malate dehydrogenases

Malate dehydrogenase isozymes of grass carp,Ctenopharyngodon idella, were identified by mitochondrial preparation and thermal denaturation. The structural and kinetic characteristics of chromatographically separated thermostable and thermolabile cMDHs were different in (1) half-life at 42°C, 10 min and 24 h, respectively, (2) optimal substrate, oxaloacetate and malate, concentrations, and (3) the apparent Michaelis-Menten constants of NADH and oxaloacetate.Total MDH activity in white muscle of 11°C-acclimated fish was about twice that of the 30°C-acclimated group. In addition, the ratio of the thermostable to thermolabile cMDH activity in white muscle of 30°C-acclimated fish was significantly higher than that of 11°C-acclimated fish. These results suggest that temperature acclimation can induce temperature compensation in MDH activity and differential expression of thermostable and thermolabile cMDH isozymes in freshwater fish.

History of sexual abuse in incarcerated adolescents with gonorrhea or syphilis

From July 1983 to June 1984, 2521 adolescents were medically screened at entry into a detention facility in New York City. A medical history, physical examination, serology for syphilis, and culture for gonorrhea were obtained from each entrant. A retrospective chart review was conducted for 136 persons with gonorrhea and/or syphilis (79 boys and 57 girls) and 136 sex-matched infection-negative controls. Several characteristics were compared including age, age at first sexual intercourse, sexual abuse history, contraceptive use, and pregnancy status. Among infected cases, 8% of males and 32% of females reported a history of sexual abuse, whereas among controls, no males and 14% of females reported abuse. A history of sexual abuse was strongly associated with gonorrhea or syphilis (odds ratio = 3.4; 95% confidence intervals, 1.5-8.0). These data suggest an association between sexual abuse and subsequent high-risk sexual behavior manifested by a gonorrhea or syphilis infection.

Fentanyl-oxygen versus fentanyl-N2O/oxygen anaesthesia in children undergoing cardiac surgery

Fentanyl-oxygen (fentanyl-O2) anaesthesia was compared to fentanyl-nitrous oxide/oxygen (fentanyl-N2O/O2) anaesthesia in 14 children undergoing cardiac surgery. Children were randomly assigned to one of the two techniques studied, with seven patients in each group. The mean age (mean +/- SE) was 3.9 +/- 0.75 years (0.5-8.25 years) and mean weight 14.7 +/- 2 kg (3.5-29.5 kg). Patients were premedicated with IM atropine 0.02 mg . kg-1 and morphine 0.2 mg . kg-1 1 hour preoperatively. They received a fentanyl bolus of 30 micrograms . kg-1 with a concomitant continuous infusion of 0.3 micrograms . kg-1 . min-1. Pancuronium 0.1 mg . kg-1 was administered immediately following the fentanyl bolus. Fifty per cent nitrous oxide was given with oxygen in one group and 100 per cent oxygen was administered to the other group. Fentanyl plasma concentrations were similar in the two groups at the various stages of surgery. There were no significant differences between the two treatment groups in systolic and diastolic blood pressure or in heart rate in response to induction, intubation, and incision. There was a significantly greater increase in systolic blood pressure after sternotomy in the fentanyl-O2 group. In addition, in six of seven patients receiving fentanyl-O2 there were events of sudden increase in blood pressure during various stages of surgery before the bypass, necessitating an additional fentanyl bolus or the addition of droperidol in four cases. Similar phenomena were not documented in the fentanyl-N2O/O2 group. Our studies suggest that fentanyl-O2 anaesthesia in the schedule described, in children undergoing elective cardiac surgery for Tetralogy of Fallot, A-V canal, and transposition of the great arteries, is not sufficient to prevent elevation in systolic blood pressure despite fentanyl plasma concentrations in excess of 20 ng X ml-1. The addition of nitrous oxide prevents this phenomenon.

Thyroid function screening in psychiatric in-patients

During a two-year biochemical screening for thyroid disease amongst 191 psychiatric admissions, 38 (20 per cent) had an abnormal result, 5 were hyperthyroid and 7 hypothyroid. Thyroid dysfunction was associated with female sex and affective psychosis, but not with age. During the three weeks before admission the patients with an abnormal result had been prescribed significantly more phenothiazines, antiparkinsonian drugs and lithium than the patients with normal thyroid function. Almost half of those with abnormal function were physically ill on admission. Despite these findings we concluded that in most patients thyroid dysfunction was not a major determinant of the psychiatric disturbance.

Gas chromatographic/mass spectrometric analysis of methylphenidate (ritalin) in serum

A gas chromatographic/mass spectrometric (GG/MS) procedure for the determination of methylphenidate in 1 mL of serum or plasma is reported employing ethylphenidate as internal standard. A 50/50 (V/V) mixture of benzene and hexane is used to extract the methylphenidate and ethylphenidate from plasma. After evaporation of solvent the residue is redissolved in 50 microL hexane. Methyl- and ethylphenidate are then derivatized by the addition of 50 ML of trifluoroacetic anhydride and the TFA derivatives are injected into a quadrupole GC/MS for analysis. This method has a lower limit of sensitivity for methylphenidate of 2.0 micrograms/L. The between-day precision study yielded coefficients of variation of 10.4% and 14.8% at methylphenidate concentrations of 25.6 and 5.2 micrograms/L respectively. The assay has been used to investigate the pharmacokinetics of methylphenidate administered to 6 children for treatment of hyperkinesis. The study yielded ranges for volume of distribution, elimination half-life, and total body clearance of 5.0-6.8 L/kg, 1.6-2.7 hours, and 1.4-2.9 L/kg-hr respectively.