Restraining good practice: Reviewing evidence of the effects of restraint from the perspective of service users and mental health professionals in the United Kingdom (UK).

Safeguarding, balancing the concept of risk with the need for public protection and its implication for the lives of individuals, is an important facet of contemporary mental health care. Integral to safeguarding is the protection of human rights; the right to live free from torture, inhuman, or degrading treatment, and having the right to liberty, security, respect, and privacy. Professionals are required to recognise all of these rights when delivering care to vulnerable people. In the United Kingdom (UK) there has been growing public concern regarding abusive practices in institutions, with a number of unacceptable methods of restraint being identified as a feature of care, particularly in mental health care. In keeping with the service user movement, and following a review of the literature, this paper discusses the evidence regarding restraint from the perspectives of service users and professionals within mental health services and considers the implications for future practice and research. In reviewing the literature, findings revealed that restraint can be a form of abuse, it's inappropriate use often being a consequence of fear, neglect, and lack of using de-escalation techniques. Using restraint in this way can have negative implications for the well-being of service users and mental health professionals alike.

Interpersonal processes and self-injury: a qualitative study using Bricolage.

INTRODUCTION: Literature on self-injury has recognized the impact on the relationship between clients and staff. RATIONALE: There is an absence of a detailed account of interpersonal processes surrounding self-injury. AIM: A Bricolage qualitative research approach was carried out in the United Kingdom that explored the interpersonal processes surrounding self-injury. METHOD: Three pairs of clients and staff were interviewed about an incident of self-injury. The interviews were thematically analysed and then synthesized producing a deeper exploration of the relationship between the client and staff. FINDINGS: An interpersonal trigger followed by anger and shame, resulted in self-injury to 'numb' these experiences. DISCUSSION: Self-injury is conceptualized as a safety behaviour to avoid shame and anger and then as a maintenance cycle that traps the client in a reinforcing and rejecting relationship. Staff interviewed were able to reflect with the clients and help them reframe these experiences. IMPLICATIONS FOR PRACTICE: Mental Health Nurses can work with clients to understand their own interpersonal cycles of self-injury. They can then reflect on their own roles in this process and avoid reinforcing the clients' negative beliefs. WHAT THE STUDY ADDS TO INTERNATIONAL EVIDENCE: This is the first international paper to explore the interconnection between the client and a professional helper in their lived experiences of self-injury.

The catcher in the why: developing an evidence-based approach to the organization, delivery and evaluation of pre-registration nurse educational programmes.

Changes to the pedagogy of pre-registration nurse education and training have become a global phenomenon. However, the evidence base to inform responses to these changes and the impact on nursing practice is limited. This paper explores the outcomes of an innovative approach aimed at ensuring responses to these drivers for change, particularly in curriculum development, the organisation, management and delivery of programmes and the enhancement of the student experience, are evidence based. This paper reports on an organisational change project undertaken in a School of Nursing in the North West of England, UK. The project involved 12 interrelated work streams used to explore aspects of the student journey from recruitment through progression to eventual employment. An evidence base was developed through a methodological bricolage that drew upon a robust and authentic mixture of systematic literature reviews, contemporaneous analysis of educational practice and evaluation of the student experience. This was used to underpin the decision making processes required to promote innovation in programme design, to increase the involvement of students in the facilitation and evaluation of their learning experiences, and helped shape the organisational changes required for embedding an evidenced-based culture in the School. Consistent and transformational leadership has been key to the project's success in communicating and managing the changes.

Re-searching for therapy: the ethics of using what we are skilled in.

Narrative inquiry as a qualitative research method appears to be growing in popularity among mental health nurses. This paper argues that there are a number of parallels between narrative inquiry and psychotherapy, and mental health nurses familiar with the practice of therapeutic engagement need to be mindful of these when using this approach to research. The symbiotic relationship between those engaged in narrative inquiry and those engaged in psychotherapeutic practice is explored in order to provide greater understanding of some of the ethical issues involved and how new researchers, supervisors and practitioners might better respond to the complexities inherent in using narrative inquiry which may itself be therapeutic. Our focus for this paper is the tensions experienced by the mental health nurse while working as a researcher when the research encounter provides a trigger that would normally elicit a therapeutic response for both participant and nurse. Using a selection of psychoanalytic theories and principles this paper explores the relationship between the processes of psychotherapy and narrative inquiry. This discussion paper is based on the authors' own research experiences of using narrative inquiry to explore a number of sensitive issues and many years of supervisory relationships with students and practitioners alike.

Constructing a bricolage of nursing research, education and practice.

Drawing upon post doctoral reflections of a shared methodology, the authors explore the use of bricolage as a way of better understanding the inter-related connections between theory, nursing practice and the felt experiences of service users. The origins of bricolage can be traced back to the work of Levi-Strauss, and Denzin and Lincoln's contribution to qualitative methodologies. Bricolage is a multifaceted approach to the research process. Differing epistemological positions and mixed methods of data collection are utilised to bring a richer understanding of human beings and the complexities of their lived experiences. For the bricoleur the object of inquiry, cannot be separated from its context, that is the language used to describe it, its historical situatedness and the social and cultural interpretations of its meaning as an entity in the world. The paper discusses the importance of being able to move beyond the notion of the research method being merely a procedure, to one that respects the complexities of the lived world.

Bordering on insanity: misnomer, reviewing the case of condemned women.

In the UK, there have been calls to develop gendered specific mental health services for women in an attempt to ensure privacy and dignity are achieved as and when women come into contact with services. This is a largely rhetorical policy objective. There are more fundamental factors affecting women's experience of mental health services that need addressing. This paper explores these issues in the context of mental health care for women who have been 'given' the diagnosis of borderline personality disorder (BPD). Borderline personality disorder effects 2% of the adult population, 75-90% of those diagnosed being women. This diagnosis continues to present considerable conceptual and therapeutic challenges for all of those involved in mental health services and it remains a categorical label that evokes a wide range of conscious and unconscious responses in mental health nurses. The paper argues that mental health nurses need to recognize the defence mechanisms involved in working with individuals who are often difficult to work with. It is only when mental health nurses can embrace and acknowledge the person in the context of their life, that the pejorative and disabling consequences of the BPD label can be eliminated, ensuring the individual's story is heard and not that which is often a pre-constituted account accompanying this diagnosis.

Learning to listen to the organisational rhetoric of primary health and social care integration.

The sustained modernisation of the UK primary health care service has resulted in individuals and organisations having to develop more integrated ways of working. This has resulted in changes to the structure and functioning of primary care organisations, changes to the traditional workforce, and an increase in scope of primary care practice. These changes have contributed to what for many staff has become a constantly turbulent organisational and practice environment. Data from a three-year project, commissioned by the North West Development Agency is used to explore how staff involved in these changes dealt with this turbulence. Three hundred and fifty staff working within primary care participated in the study. A multimethods approach was used which facilitated an iterative analysis and data collection process. Thematic analysis revealed a high degree of congruence between the perceptions of all staff groups with evidence of a generally well-articulated, but often rhetorical view of the organisational and professional factors involved in how these changes were experienced. This rhetoric was used by individuals as a way of containing both the good and bad elements of their experience. This paper discusses how these defense mechanisms need to be recognised and understood by managers so that a more supportive organisational culture is developed.

Closeness, chaos and crisis: the attractions of working in acute mental health care.

This paper makes a case for the attractiveness of acute mental health inpatient nursing (acute nursing) and argues that an altered perception of this work is essential if we are to provide the most acutely mentally ill and vulnerable people with a stable and expert nursing workforce. The discussion draws on an ethnographic study conducted in an inner-city psychiatric unit in England and the advantages of this method for understanding nursing work are described. Within our findings, we set out two overarching themes: the contextual realities of the contemporary acute ward and features of attraction that encourage nurses to work in the acute care setting. The former includes nurses' responsibility for the total ward environment and the latter the 'comfort of closeness' and 'surviving and thriving in chaos and crisis'. In conclusion, we argue that despite the unpopularity of the acute inpatient mental health environment, the highly sophisticated skills employed by acute nurses actually ensure the promotion of health for the majority of service users.

The shackles of abuse: unprepared to work at the edges of reason.

The shackles of abuse: unprepared to work at the edges of reason Childhood sexual abuse is an international public health problem. Research suggests similar prevalence rates in both Western and non-Western societies. The long-term consequences of child sexual abuse include wide ranging mental health problems in adult life. Psychiatric services and, in particular, counselling has been highlighted as being the most helpful to those who have experienced child sex abuse. This evidence base should be informing mental health nursing education and practice. However, we argue there is a divergence between the discourse of evidence-based theory and practice reality. The aim of this paper is to explore the preparedness of mental health nurses to work with adults who have experienced sexual abuse during their childhood. It is the first part of a three-part research project and reviews the literature relating to how (and if) mental health nurses are prepared to work with those who have sexual abuse histories. An important issue considered in this review is the impact upon patient/nurse relationships as a consequence of the nurse themselves being survivors of sexual abuse. We argue that a number of conflicting discourses need to be addressed, if mental health nurses are to be appropriately prepared to offer cogent, sensitive care to those in their care who are shackled to their past sexual abuse through the confines of their current mental illness.

Service users, metaphors and teamworking in mental health.

Despite the United Kingdom's recent governmental mental health policy directives aimed at strengthening professional collaboration and increasing service user involvement, the prevailing mental health care culture remains steeped in a discourse of treatment and care, control and compliance and professional expertise. Drawing upon the data collected during the two phases of a 2-year national evaluation undertaken for the English National Board for Nursing, Midwifery and Health Visiting, the perceptions of a group of mental health service users in relation to their experiences and contact with the multi-professional team are explored. A series of metaphorical descriptions were developed with these service users drawn from their experience. These begin to illuminate a realistic way of thinking about how teams are set up, how and why they carry out their various roles, and the need to think in non-professional terms about the relationships that are developed with service users. A hierarchy of power was noted that was congruent with the outcomes of other studies. However, there was also a concurrent acknowledgement of the 'usefulness'(to the individual service user) of each of the professional group members. This appeared to have been constructed alongside the power hierarchy and serves to illustrate how individual service users sought to find an accommodation within the social system they were placed in. This paper argues however, that the use of metaphors, as a form of shared communication, can be an effective first step in working towards this objective. Working in the way described here can allow for a greater shared understanding of what each group is experiencing and help ensure that future service development reflects a broader view of the mental health care world.

Ignoring the evidence dictating the practice: sexual orientation, suicidality and the dichotomy of the mental health nurse.

International epidemiological studies demonstrate that gay and bisexual males are four times more likely to report a serious suicide attempt than their heterosexual counterparts. Data on completed suicides, usually derived from mortality statistics misrepresent the rate of suicides among homosexual populations. However, an increasing number of studies comparing representative samples of gay, lesbian and bisexual youths with heterosexual controls demonstrate increased rates of mental health problems and subsequent suicide among the homosexual population. Homosexual orientation must therefore be considered a risk factor for mental distress and as such should be a focus for any contemporary public health agenda. One of the difficulties of addressing the problem through a public health agenda is the juxtaposition proffered by our political and social environment. The Diagnostic and Statistical Manual of Mental Disorder ceased to define homosexuality as pathological in 1973 replacing it with a new 'illness' of 'gender identity disorder'. Until recently in England, Section 28 of the Local Government Act (1988), forbidding the promotion of homosexuality, further reinforced negativity towards this group of people. This compounded the negative mental health consequences for those developing a gay sexual orientation in a climate of heterosexism. Current health care policy in England concerns itself with the rising number of suicides among young people but fails to acknowledge the importance of the research findings relating to gay people by integrating them into the development of mental health policy. This paper reviews the literature relating to homosexual people and suicidality, and addresses the seriousness of a policy rhetoric which results from ignoring the evidence while dictating mental health nursing practice.

The Escherichia coli multidrug transporter EmrE is a dimer in the detergent-solubilised state.

EmrE is a multidrug transporter that utilises the proton gradient across bacterial cell membranes to pump hydrophobic cationic toxins out of the cell. The structure of EmrE is very unusual, because it is an asymmetric homodimer containing eight alpha-helices, six of which form the substrate-binding chamber and translocation pathway. Despite this structural information, the precise oligomeric order of EmrE in both the detergent-solubilised state and in vivo is unclear, although it must contain an even number of subunits to satisfy substrate-binding data. We have studied the oligomeric state of EmrE, purified in a functional form in dodecylmaltoside, by high-resolution size-exclusion chromatography (hrSEC) and by analytical ultracentrifugation. The data from equilibrium analytical ultracentrifugation were analysed using a measured density increment for the EmrE-lipid-detergent complex, which showed that the purified EmrE was predominantly a dimer. This value was consistent with the apparent mass for the EmrE-lipid-detergent complex (137 kDa) determined by hrSEC. EmrE was purified under different conditions using minimal concentrations of dodecylmaltoside, which would have maintained the structure of any putative higher oligomeric states: this EmrE preparation had an apparent mass of 206 kDa by hrSEC and equilibrium analytical ultracentrifugation showed unequivocally that EmrE was a dimer, although it was associated with a much larger mass of phospholipid. In addition, the effect of the substrate tetraphenylphosphonium on the oligomeric state was also analysed for both preparations of EmrE; velocity analytical ultracentrifugation showed that the substrate had no effect on the oligomeric state. Therefore, in the detergent dodecylmaltoside and under conditions where the protein is fully competent for substrate binding, EmrE is dimeric and there is no evidence from our data to suggest higher oligomeric states. These observations are discussed in relation to the recently published structures of EmrE from two- and three-dimensional crystals.

Mental health practice and the rhetoric-reality gap.

This paper had its genesis in a national project, sponsored by the English National Board for Nursing, Midwifery and Health Visiting, to explore team working within mental health practice. The project extended over a 2-year period and utilized various methods of data collection. However, this paper focused on data, from the national survey and informal interviews (based in eight regions), that addressed specific issues within the practitioner group. Of the 800 questionnaires sent out 26% were returned. Fifty-three percent of the returns were from practitioners, 14% user/carers and 33% educationalists. Our focus was that of the practitioners. This group had a response rate of 50% (i.e. 50% of the surveys sent out to practitioners were returned). A content analysis of 100 interviews was used to triangulate the data. Whilst the original brief was to explore team working the survey also highlighted data that indicated a common understanding of what mental health practitioners do and what they say they do and that, although there was a commonality of vocabulary, different practices existed between and within regions. This is the focus of this paper. We argue, from our findings, that different practice is a result of 'habitus'. Whilst practitioners reported that they subscribe to a national agreement of meaning, there is a rhetoric-reality gap: that which is said to be done is not what is, in fact, practised. At the local level we argue that working within the habitus (educationally) can address the rhetoric-reality gap. However, we recommend further studies in order to explore how working within the habitus can address this matter across regions.

The mental health assistant practitioner: an oxymoron?

The United Kingdom is currently experiencing a recruitment and retention crisis in its nursing workforce. Mental health care is a particular problem area. Widening access to health and social care careers is a challenge for educational and health care organizations. This discussion paper examines the congruence between an educational programme aimed at developing Mental Health Assistant Practitioners' and the organizational responses to the subsequent opportunities for practice innovation within mental health care services. Whilst the 'learning while working' philosophy of the educational programme has been enthusiastically embraced by many health care organizations, the change in management required for using these assistant practitioners in service innovation appears beset by organizational, cultural and professional concerns. Not least of which are the often ambiguous concepts of the role and purpose of being a mental health nurse. This paper argues that if current mental health nurses are unclear about their role it is oxymoronic to establish the mental health assistant practitioners.

Teamwork in mental health: rhetoric and reality.

This paper offers a discussion of team-working in mental health. It is based upon a 2-year study funded by the English National Board for Nursing, Midwifery and Health Visiting. The authors advocate that team-working should be studied situationally. The paper begins therefore by highlighting contextual tensions and paradoxes that create potential problems for effective team-working. It is argued that team-working is better caught as opposed to being taught. This involves a layered reading of vignettes and case studies, as well as 'hands on' experiences of team-working. Such an approach foregrounds for inspection the complexities and dilemmas of policy, models of practice and team-working patterns. As a result, the students build their own evidence-base, which is not built on the ideal (or optimal) but is located in the real everyday habitus of individuals in healthcare settings. This, the authors feel, is more likely to shift terms such as team-working, partnerships and so on, from merely remaining a healthy rhetoric.

Practice nursing: an evaluation of a training practice initiative.

Globally, health care is moving towards a primary care approach. In the UK initiatives for nurses wishing to gain experience in primary and community care may be crucial with the advent of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). This paper outlines an initiative in practice nursing, developed as a pilot study by a Health Authority. The training practice initiative was aimed at nurses returning to practice and offered them an experiential and supportive career pathway into primary care. The evaluation (carried out over 1 year), highlighted that those primarily involved in the initiative--the trainees, educators and general practitioners--felt it had been successful, especially in relation to professional development issues. The funding bodies for the initiative, who previously had concerns over the recruitment and retention of practice nurses, were also optimistic that the support networks which developed as a result of the initiative had raised morale. The paper suggests several educational, organizational and professional issues which arose from the evaluation exercise. Further, it suggests how this initiative, in an extended form, could provide an effective basis for the training and development of nursing staff in PCGs/PCTs.

The new NHS: the changes, challenges and opportunities.

The competition based market system is to be disbanded and will be replaced by more alliances, partnerships and collaborative working practices. Children's nurses are ideally placed to respond to the new NHS call for greater involvement of nurses in the commissioning and service development decision making processes. Primary care groups will build upon the best of existing practice, and offer an opportunities for GPs and nurses working in the community to spread the benefits of their experience more widely.

Growth-dependent accumulation of monoalkylglycerol in Madin-Darby canine kidney cells. Evidence for a role in the regulation of protein kinase C.

1-O-Alkyl-sn-glycerol (alkylglycerol) forms the backbone of complex ether-linked glycerolipids, including biologically active lipids such as platelet-activating factor. Synthetic alkylglycerol itself possesses several potent pharmacological activities and has been shown to inhibit protein kinase C (PKC) in vitro. In spite of these properties, free alkylglycerol has been regarded only as a potential product of the inflammatory degradation of complex ether lipids rather than a natural cell constituent. To explore the possibility that endogenous alkylglycerol functions as a physiological regulator in normal cells, we measured its content, along with related monoglycerides and diglycerides, by high performance liquid chromatography and gas-liquid chromatography in Madin-Darby canine kidney (MDCK) cells. The content of free alkylglycerol increased up to 20-fold during the growth of MDCK cell cultures to a confluent density. The increase was greatest during the log phase of growth, in which the content of alkylglycerol rose from 6.0 +/- 1.3 nmol/10(8) cells in preconfluent cultures to 23.6 +/- 3.4 nmol/10(8) cells in confluent cultures. Analysis of the molecular species of alkylglycerol showed that the higher content in quiescent MDCK cells was due primarily to an increase in 1-O-octadecyl-sn-glycerol. In contrast, the levels of monoacylglycerol and the PKC activator diacylglycerol were lower in confluent, quiescent cultures than in preconfluent, proliferating cultures. A similar pattern of changes in the monoglyceride and diglyceride content was observed in interleukin-3-dependent CFTL-12 mast cells when cell proliferation was blocked by growth factor withdrawal. Growth of MDCK cells to a confluent density resulted in a decrease in particulate PKC enzyme activity to a level that was only 6% of that in proliferating cells. To explore whether the accumulation of cellular alkylglycerol contributes to growth-dependent changes in PKC activity, we examined the effects of adding alkylglycerol to the activity and subcellular distribution of the enzyme in MDCK cells. Treatment of cells with 1-O-dodecyl-sn-glycerol resulted in a decrease in the activity of membrane-associated PKC activity and inhibited 12-O-tetradecanoylphorbol-13-acetate-stimulated translocation of PKC from the cytosol to the membrane fraction. Alkylglycerol was also shown to inhibit the activity of purified PKC in vitro when present at levels similar to that of the diacylglycerol activator. We propose that the accumulation of alkylglycerol during the growth of MDCK cells to a confluent density contributes to the decrease in PKC activity. The control of cellular alkylglycerol levels may be a novel mechanism for the regulation of cellular physiology.

Inhibition of phorbol ester-stimulated arachidonic acid release by alkylglycerols.

Although synthetic analogs of alkylglycerol (AG), such as dodecylglycerol, possess potent biological activities, their mechanism of action has not been determined. We recently detected substantial amounts of AG in unstimulated MDCK cells (Warne, T.R. and Robinson, M. (1991) Anal. Biochem. 198, 302-307) raising the possibility that the endogenous compound may act as a biological mediator. In this study, we examined the effects of synthetic AG on the release of arachidonic acid and arachidonate metabolites (AA) from Madin Darby canine kidney (MDCK) cells in response to 12-O-tetradecanoylphorbol-13-acetate (TPA) in order to characterize its effects on this signalling pathway. Treatment of MDCK with AG potently inhibited the release of AA during subsequent stimulation with TPA. Dodecylglycerol, the most effective of a series of alkyglycerols tested, was active at concentrations as low as 3 microM. The sn-1 and sn-3 forms of AG were found to be equally potent inhibitors. The effects of AG on AA release were not the result of arachidonic acid redistribution among cellular lipids and were independent of the phospholipid source of the released AA. AG did not inhibit the release of AA from MDCK cells when bradykinin was used as a stimulus, indicating selectivity for the effects produced by phorbol esters. These results show that AG can function as a potent and specific inhibitor of TPA-mediated AA release. The ability of AG to regulate this signalling pathway in intact MDCK cells, together with its natural occurrence, suggests a potential bioregulatory role for the endogenous compound as an inhibitor of protein kinase C.

Accumulation of fatty alcohol in MCF-7 breast cancer cells.

The MCF-7 cell line (human breast epithelial cells) accumulates fatty alcohols. The fatty alcohols were identified as C16:0, C18:0, and C18:1 alcohols by thin-layer chromatography and gas chromatography/mass spectrometry. This accumulation of alcohols in MCF-7 was found in cultures of MCF-7 cells obtained from other laboratories but not in a variety of unrelated cell lines. The presence of the alcohols suggested an aberrant ether lipid metabolism in the MCF-7 cells. Therefore, the capacity for either lipid biosynthesis was evaluated using cells incubated with either [14C]stearyl alcohol or [14C]stearic acid. MCF-7 cells incorporated less than 0.4% of the [14C]alcohol into ether-linked phospholipids, whereas the AB589 breast epithelial cells, used as a "normal control" for comparisons, did not accumulate fatty alcohol and incorporated approximately 20% of the radiolabeled alcohol into phospholipids containing ether linkages. Although the MCF-7 cells were unable to effectively incorporate the fatty alcohol into ether linkages, the cells were able to oxidize the alcohol to fatty acid. When incubated with [14C]stearic acid, the conversion to radiolabeled fatty alcohol in MCF-7 cells was approximately four times higher than the alcohol levels found in AB589 cells. While deficient in the ability to synthesize ether linkages, the MCF-7 cells did incorporate radiolabeled hexadecylglycerol, a precursor containing an ether linkage, into phospholipids. Collectively, the data indicate that the MCF-7 cells possess a deficiency in the alkyl DHAP synthase activity. A near absence of ether-linked lipids in the MCF-7 cells was indicated by the radiolabeling studies, and this finding was corroborated by results from HPLC analysis. Analyses of the partial glycerides, obtained from the enzymatic hydrolysis of cellular phospholipids, found only trace levels of ether lipids in the MCF-7 cells. The aberration in ether lipid biosynthesis did not correlate with the expression of the multidrug resistance phenotype in a series multidrug resistant MCF-7 variants. The results are discussed relative to the use of the MCF-7 cells as a model for investigations of ether lipid biosynthesis and the cellular physiology of ether lipids.