An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint.

UNLABELLED: WHAT IS KNOWN ON THE SUBJECT?: There is emerging evidence highlighting the counter therapeutic impact of the use of restraint and promoting the minimization of this practice in mental health care. Mental health nurses are often the professional group using restraint and understanding factors influencing their decision-making becomes critical. To date, there are no other published papers that have undertaken a similar broad search to review this topic. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Eight emerging themes are identified as factors influencing mental health nurses decisions-making in the use of restraint. The themes are: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. 'Last resort' appears to be the mantra of acceptable restraint use, although, to date, there are no studies that specifically consider what this concept actually is. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These findings should be considered in the evaluation of the use of restraint in mental health settings and appropriate strategies placed to support shifting towards restraint minimization. As the concept of 'last resort' is mentioned in many policies and guidelines internationally with no published understanding of what this means, research should prioritize this as a critical next step in restraint minimization efforts. INTRODUCTION: While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses' decision-making related to restraint use are therefore warranted. AIM: To explore what influences mental health nurses' decision-making in the use of restraint. METHOD: An integrative review using Cooper's framework was undertaken. RESULTS: Eight emerging themes were identified: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. These themes highlight how mental health nurses' decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors. CONCLUSION: Research to further understand the experience and actualization of 'last resort' in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed.

A cross-sectional observational study of healthcare professional views of factors affecting teenage adherence with antipsychotic medication.

Delays in effective treatment of a first episode psychosis can result in more severe symptoms, a longer time to achieve symptom control and a poorer quality of life; yet around 40% do not take antipsychotic medication as prescribed. There is evidence that patients and staff have different perceptions of what affects adherence with medication. Research in adults suggests healthcare professionals and patients understand the importance of good insight in promoting adherence with medication for schizophrenia; however, healthcare staff may overestimate the impact of side effects and underestimate the importance of medication effectiveness. There is also some evidence to suggest that motivations to take prescribed medication may differ in first and multi-episode psychosis. This research therefore sought views of staff working with adolescents diagnosed with first episode psychosis about what factors affected adherence with antipsychotic medication. Staff responding to the survey felt that young people were more likely to take medication if they felt it would make them better, prevent relapse and if they had a positive rapport with staff. As in an adult population, side effects, particularly weight gain, sedation and muscular side effects, were expressed as a common reason for poor adherence. Doctors and nurses assigned differing importance to parameters such as family views of medication, fear of admission and a preference for cannabis over medication suggesting that views may differ between professional groups Views of young people will be obtained in the next phase of the research study to enable comparison with staff views and consideration of staff interventions to better promote medication adherence. Antipsychotic medication is an effective treatment for first episode psychosis; yet 40% of patients do not take medication as prescribed. Previous research in adults with schizophrenia comparing healthcare professional and patient views suggests that while healthcare professionals recognize the importance of insight in promoting medication adherence, they underestimate the importance of medication efficacy and overestimate the impact of side effects. It was hypothesized that staff in this study would also recognize the importance of insight and positive medication attitudes in teenagers with psychosis, but overestimate the impact of side effects on medication adherence. This cross-sectional observational study sought staff views about factors affecting antipsychotic medication adherence in those aged between 14 and 18 years. An online survey was distributed and 60 responses were subsequently returned. Staff felt that good medication insight as well as positive relationships with staff were important determinants of good medication adherence. The most important influences of poor adherence were poor insight, side effects of medication and a wish to exert personal control around medication decisions. The results therefore confirmed the initial hypothesis. Published literature also provides support for some, but not all, of the staff views expressed in survey responses.

The Eileen Skellern Lecture 2014: physical restraint: in defence of the indefensible?

Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. The study aims to explore three common 'defences' to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. In order to do this, three key defences for its use will be challenged using the literature. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be severely traumatized by the use of restrictive practices and there is a drive to examine, and reduce the use and impact of using these models that incorporate trauma informed care (TIC) and person centredness.

Staff and relatives' perspectives on the aggressive behaviour of older people with dementia in residential care: a qualitative study.

Staff and relative perspectives on patient aggression in dementia care units are seriously under researched in the U.K. Any work that has been conducted has relied upon quantitative studies. Qualitative research on aggression management in older peoples services are rare. In-depth views that can offer insights into causation and management strategies are therefore under represented in the literature. In order to investigate this issue further we interviewed a number of nursing staff and relatives in four U.K. care homes in the North West of England. Using a combined approach of one-to-one interviews (for staff) and focus groups (for relatives) we explored their views as to the reasons for and ways of responding to aggressive behaviour. This was part of a larger study reported upon elsewhere. Using thematic analysis we found similar results from both staff and relatives and as such their views were categorized into two broad areas: causation and management. In regards to causation we noted three sub-themes; internal, external and interpersonal factors which are further subdivided in the paper and for management two broad categories: the compassionate approach and 'don't go in strong'. The results indicated that staff in the participating units embraced a person-centred approach to aggression management. They predominantly respond to aggressive incidents with interpersonal strategies, such as distraction as opposed to medication or restraint. Overall they adopt a person centre approach to patient care. Relatives were clear in their perceptions of aggression as an interpersonal challenge, which is compounded or mediated by the illness of dementia. Consequently they were positive in their views of staff using non-coercive interventions. While the results of this and our earlier study are promising suggesting a less invasive approach to this aspect of dementia care, given the limitations of a small sample, more research of a similar nature is warranted. Findings from multidimensional studies can then provide a sounder basis for health and social care education, and person centred informed practice to reduce the incidence of aggression through preventative strategies.

Aggression in a high secure hospital: staff and patient attitudes.

Responding to aggressive behaviour is a key activity for nurses and other care staff in high secure hospitals. The attitudes and beliefs of staff regarding patient aggression will influence the management strategies they adopt. Patients will also hold attitudes regarding the causes of and best ways to respond to aggressive behaviour. This study measured the attitudes towards aggression of staff (n= 109) and patients (n= 27) in a high secure hospital in the UK using the Management of Aggression and Violence Attitude Scale (MAVAS). There was considerable concordance of views, staff and patients disagreeing on only two items on the MAVAS. Aggression was felt to have a range of causes, embracing factors internal to the person, factors in the external environment and situational or interactional factors. Interpersonal means of managing aggression were supported, but both staff and patients also advocated the use of controlling management strategies such as medication, seclusion and restraint. The implications of these findings for aggression management in high secure settings are discussed in the light of best practice guidelines that promote interpersonal approaches over controlling strategies.

Effect of water management, arsenic and phosphorus levels on rice in a high-arsenic soil-water system: II. Arsenic uptake.

Rice consumption is one of the major pathways for As intake in populations that depend on a rice diet in several countries of South and South-east Asia. Pot experiments were undertaken to investigate the effects of water management (WM), arsenic (As) contaminated soil-water and Phosphorus (P) rates on As uptake in rice plants. There were 18 treatments comprising of three each of As rates (0, 20 and 40 mg kg(-1) soil) and P rates (0, 12.5 and 25 mg kg(-1) soil) and two WM (aerobic and anaerobic) strategies on winter (boro var. BRRI dhan 29) and monsoon (aman var. BRRI dhan 32) rice at the Wheat Research Center (WRC), Nashipur, Dinajpur, Bangladesh. Arsenic concentrations in rice grain and straw increased significantly (P ≤ 0.01) with the increasing As rates in the soil. Arsenic availability in soil pore-water solution was less (58%) under aerobic WM (redox potential-Eh=+135 to +138 mV; pH-6.50 at 24.3 °C) as compared to anaerobic WM (flooded: Eh=-41 to -76 mV; pH-6.43 at 23 °C). The highest total grain As content 2.23 ± 0.12 mg kg(-1) and 0.623 ± 0.006 mg kg(-1) was found in T(6) (P(12.5)As(40)-anaerobic) and T(9) (P(25)As(40)-anaerobic) in BRRI dhan 29 and BRRI dhan 32, respectively, which was significantly higher (41-45%) than in the same As and P treatments for pots under aerobic WM. The As content in rice straw (up to 24.7 ± 0.49 ppm in BRRI dhan 29, 17.3 ± 0.49 mg kg(-1) in BRRI dhan 32 with the highest As level) suggested that As can more easily be translocated to the shoots under anaerobic conditions than aerobic condition. BRRI dhan 29 was more sensitive to As than BRRI dhan 32. Under aerobic WM, P soil amendments reduced As uptake by rice plants. The study demonstrated that aerobic water management along with optimum P amendment and selection of arsenic inefficient rice varieties are appropriate options that can be applied to minimize As accumulation in rice which can reduce effects on human and cattle health risk as well as soil contamination.

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings.

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.

Spatial variability of arsenic concentration in soils and plants, and its relationship with iron, manganese and phosphorus.

Spatial distribution of arsenic (As) concentrations of irrigation water, soil and plant (rice) in a shallow tube-well (STW) command area (8 ha), and their relationship with Fe, Mn and P were studied. Arsenic concentrations of water in the 110 m long irrigation channel clearly decreased with distance from the STW point, the range being 68-136 microg L(-1). Such decreasing trend was also noticed with Fe and P concentrations, but the trend for Mn concentrations was not remarkable. Concerning soil As, the concentration showed a decreasing tendency with distance from the pump. The NH(4)-oxalate extractable As contributed 36% of total As and this amount of As was associated with poorly crystalline Fe-oxides. Furthermore only 22% of total As was phosphate extractable so that most of the As was tightly retained by soil constituents and was not readily exchangeable by phosphate. Soil As (both total and extractable As) was significantly and positively correlated with rice grain As (0.296+/-0.063 microg g(-1), n=56). Next to drinking water, rice could be a potential source of As exposure of the people living in the As affected areas of Bangladesh.

The use of outreach clinics for teaching undergraduate restorative dentistry.

AIM: To examine the experience of being an outreach teacher of undergraduate restorative dentistry; to describe the desirable characteristics of such teachers; and to consider the management of outreach teaching. DESIGN: A three year pilot of an outreach course in fourth year restorative dentistry began in 2001. Students spent one day per week treating adults in NHS community dental clinics, run by Primary Care Trusts (PCTs). Action research involved monitoring meetings with students, clinic staff (dental teachers and nurses), and PCT clinical service managers. These data are supplemented by an independent evaluation involving interviews with dental school academic staff, and an account by an outreach teacher. RESULTS: Outreach is a different and more demanding context for teaching restorative dentistry than the dental hospital, characterised by isolation, management responsibility, pressure, a steep learning curve, and stress. The desirable characteristics of outreach teachers are those which enable them to cope in this environment, together with a student-centred teaching style, and the appropriate knowledge. Management of teaching passed to the PCTs and this created an additional workload for them in relation to staffing, risk, and service-based issues. Four teaching surgeries were the maximum for a satisfactory level of patient care and student supervision. A key issue for the dental school is quality. The changes to teaching and the teaching environment introduced during and after the pilot to address problems identified are described. CONCLUSION: In developing facilities to enable students to benefit from the advantages of outreach, dental schools should recognise that the characteristics of the outreach environment need to be taken into account during planning, that staff selection is a critical success factor, and that an ongoing proactive approach to organisational arrangements and to the support of teaching staff is necessary.

A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children.

This cluster randomised controlled study assessed the effectiveness of twice-yearly applications of fluoride varnish as a public health measure to reduce dental caries in children living in relatively deprived communities. The test (n = 334) and control (n = 330) children in 2 school years (unit of randomisation) attended 24 state primary schools and were 6-8 years of age at the start. Good baseline balance was found. Duraphat varnish was applied at school on 5 occasions over 26 months, by dental therapists. A combined visual and fibre-optic transillumination examination included all surfaces of primary and first permanent molars at baseline and after 26 months for small and large enamel and dentine lesions. At the final examination the only statistically significant difference was in the caries increment for small enamel lesions in the primary dentition, with the test children having fewer lesions. This study failed to demonstrate that the twice-yearly application of fluoride varnish provided at school reduced dental caries in children living in this community. The low level of response and a lower than expected caries increment had a major impact on the effectiveness of the intervention, since the children who participated were least likely to have benefited from the programme, whereas those who might have benefited did not consent.

Challenges associated with the evaluation of a dental health promotion programme in a deprived urban area.

OBJECTIVE: This paper reports the results of a community trial to measure the clinical impact of a linked series of interventions on Early Childhood Caries (ECC) and general caries levels among five-year-old children. It exemplifies the problems of undertaking population based interventions in deprived communities. RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the active intervention PCG, the other the comparison PCG. Children in the active PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Clinical examinations were undertaken on a cohort of 5-year-old children in both active and comparison PCGs. SETTING: In the active PCG, children who attended designated clinics for their 8-month developmental checks and/or MMR inoculations at 12 to 15 months, were given gift bags, the first contained a trainer cup, the second fluoride toothpaste (1450 ppm F) and toothbrush. Parents were also given written, pictorial and verbal advice on oral care. Further supplies of toothpaste and brushes were posted to the children's homes at 20, 26 and 32 months. When five years of age children in the two PCGs were examined in school. OUTCOME MEASURES: Severity and prevalence of ECC and general caries. Levels of participation. RESULTS: Among participants in the active PCG the prevalence of ECC, general caries and extraction experience and mean dmft (20%: 54%: 3%: 2.2) were lower than in 'participants' in the comparison area (32%: 64%: 12%: 3.7). All differences were statistically significant. When all children (participants and non-participants) in the two PCGs were compared, the differences were much reduced (30%: 63%: 6%: 3.1 vs. 32%: 64%: 12%: 3.6). A higher proportion of children in the active PCG area (47%) were found not to have participated in the interventions, when compared to 21% in the comparison area. Disease levels in the non-participants in the active PCG were particularly high. The impact of participation bias, changes in baseline balance, population mobility and alternative study design on outcomes are explored. CONCLUSION: The impact of non-participation in a deprived, urban conurbation with high levels of population mobility are sufficient to dilute the impact of a health intervention such that few benefits are discernible at a population level.

Aggressive behaviour by people with dementia in residential care settings: a review.

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.

The effect of a training course on mental health nurses' attitudes on the reasons of patient aggression and its management.

Aggression in healthcare systems poses a major problem for nurses because they are the most susceptible to suffer violence. Studies demonstrate that attitudes of nurses influence their behaviour regarding aggression and violence. Training programmes can positively change nurses' attitudes. This quasi-experimental study aimed to examine the effects of a systematic training course in aggression management on mental health nurses' attitudes about the reasons for patients' aggression and on its management. Sixty-three nurses (29 in the intervention and 34 in the control group) participated in this quasi-experimental pre-test and post-test study. The attitude of the participants of a training course was recorded by the German version of the Management of Aggression and Violence Attitude Scale (MAVAS). No significant attitude changes occurred in the intervention group at post-test. It is concluded that trainings intending to influence attitudes regarding the reason for patient aggression should consider the impact of the pedagogical quality of the training course, organizational support, and the user's perception. Moreover, it remains questionable to what extent a single instrument of measurement can record attitude changes.

Low grade multiple myeloma that presented as a labial swelling -- a case report.

Myeloma is a disease of the bone marrow in which there is malignant proliferation of plasma cells. Myeloma is usually associated with the accumulation of a monoclonal immunoglobulin or light chains in plasma and subsequently an increase in light chains in the urine (Bence-Jones proteins). Renal failure can occur and bone destruction in the axial skeleton may ensue with pain and fractures. Amyloidosis associated with multiple myeloma is a relatively common finding. The most frequently reported oral sign of amyloidosis is macroglossia. There are numerous cases in the literature of amyloid deposition in tongues related to multiple myeloma. However, none of these cases describe amyloid deposition surrounding arteries in the oral cavity. We therefore report a case of an innocuous lower labial swelling, which subsequently led to the diagnosis of amyloid deposition surrounding an artery, the cause of which was later shown to be multiple myeloma.

A staged intervention dental health promotion programme to reduce early childhood caries.

OBJECTIVE: This paper reports the results of a community trial to assess the effects of a multi-stage dental health promotion programme in reducing Early Childhood Caries (ECC). RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the test Primary Care Group (PCG), the other the control PCG. Children in the test PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Interviews were conducted with parents of children aged 21 months and clinical examinations were undertaken on a larger cohort of children aged 3-4 years in test and control PCGs. SETTING: The interventions were gift bags containing a trainer cup, toothpaste containing 1,450 ppm F and toothbrush, and advice given to the children's parents on attendance at designated clinics and medical practices and further paste and brushes posted to the children's homes. Parents were interviewed on the telephone. Examinations took place at Children's Centres and nursery departments attached to primary schools. OUTCOME MEASURES: Severity and prevalence of ECC and general caries and proportion of parents reporting adopting dentally healthy behaviours. RESULTS: In the test PCG the prevalence of ECC in children who had received the interventions was 16.6% compared with 23.5% of children in the control area, a reduction of 29% (p=0.003). The mean dmft (1.17) and prevalence of general caries experience (28.7%) in the test children were also significantly lower than for children in the control PCG (1.72: 39.2%) (p=0.001). Analysis from a community perspective, which included data from all children examined in both areas, showed the prevalence of ECC in the test and control PCGs was 21.3% and 22.8% respectively and the mean dmft 1.47 and 1.72. The proportion with general caries experience remained statistically significant in favour of the test area 33.8% vs 39.9% (p=0.01). Parents in the test PCG were more likely to report cessation of bottle use (33% vs 18%), use of sugar-free drinks (49% vs 24%), commencement of brushing before first birthday (45% vs 27%) and twice daily brushing (52% vs 34%). CONCLUSION: The parents who received this multi-stage intervention were more likely to report adoption of three positive oral health behaviours; using a trainer cup from one year of age, using safe drinks and brushing twice daily with a fluoride toothpaste. The programme failed to reduce the prevalence of ECC in the community but the prevalence of ECC and general caries experience among the children who participated was less than among children in the control PCG.

Patients treated by dental students in outreach: the first year of a pilot project.

This paper describes the patients treated by 4th year undergraduate students during the first year of a pilot outreach course to teach Restorative Dentistry in community clinics in 2001-02. Data were collected from 908 summaries of patient treatment completed by the students, and from 139 patient questionnaires. Some 75% of patients were aged between 16 and 64, 58% were female, and 16% had dental phobia or anxiety. Most lived locally to the clinic and 41% made their initial contact as an emergency or drop-in. Some 37% made only a single visit (including children treated as emergencies) but 22% made six or more visits. Did not attend (DNA) was a problem and 18% of patients DNA to complete their treatment. Students undertook the full range of restorative procedures, with the emphasis on direct restorations, preventive treatment and advice, scaling, extractions and emergency treatment. Patients' main reasons for attending the clinic were lay recommendation, the need for treatment, convenience, free treatment, or the lack of access to a dentist. Some 30% said they did not have or did not know of an alternative source of dental care, and half had not seen a dentist for at least 2 years. The study demonstrates that despite difficulties related to attendance, a suitable patient base can be established offering students the opportunity to provide comprehensive care for adults in a primary care setting.