Learning from practice? Mental health nurses' perceptions and experiences of clinical supervision.

In recent years nursing as a whole has moved from a position of apparently little manifest concern in the issue of 'clinical supervision' to a veritable explosion of interest which is beginning to find expression in the literature. Beginning with a discussion of clinical supervision from within a psychodynamically informed interpersonal nursing framework this paper reports on a small scale qualitative inquiry which aimed to explore mental health nurses' perceptions and experiences of clinical supervision. Analysis of data derived from a series of semi-structured interviews provides very encouraging early indications that mental health nurses are becoming better able to reflect upon the nature of their own formative learning needs and so to take seriously their need for professional support as they strive towards a more therapeutic relationship with their patients. However, whilst all of the participants in the study had a positive perception of the potential value of clinical supervision, there is clear evidence to suggest that their actual experience was that 'good enough supervision' was more the exception than the rule. The participants' perceptions and experiences are described and the implications for research, practice, education and the management of service delivery systems are outlined.

Cognitive disturbances in Parkinson's disease.

To test the hypothesis that the cognitive impairments that accompany Parkinson's disease (PD) arise from frontal lobe dysfunction, patients with idiopathic PD and controls were tested on a neuropsychological battery that included measures of anterograde memory, visuospatial perception, and naming, as well as several tests that are known to be sensitive to lesions of the frontal lobes. PD patients of normal mental status as measured by the Mini-Mental State Examination performed normally on the naming, line orientation, and verbal recognition memory tests but exhibited deficits on verbal recall. On tests of frontal lobe function, these patients showed mild deficits on a category fluency task and on the Wisconsin Card Sorting Test. However, their errors on the latter were not typical of patients with frontal lesions, and they performed normally on a letter fluency task and exhibited normal release from proactive interference. Patients of lower than normal mental status performed poorly on nearly all of the cognitive tasks including confrontational naming, line orientation, and recognition memory, suggesting that their cerebral dysfunction extended beyond subcortical-frontal circuits. The present study supports the usefulness of the Mini-Mental State Examination for cognitive screening of PD patients, but does not support the hypothesis that the cognitive impairments in PD arise principally from disruption of frontal lobe functioning.

Language functioning after bilateral prefrontal leukotomy.

Three groups of patients with orbital frontal lesions secondary to leukotomy were compared to psychiatric and normal control groups on a series of tasks involving language. The results indicated that chronic orbital frontal lesions, at least in the patients in this study, do not affect language as defined by the tasks used in the study. The frontal lobes, when implicated in language, appear to require dorsal-lateral or medial cortical involvement.

The effects of prefrontal leucotomy on visuoperceptive and visuoconstructive tests.

Visuoperceptive and visuoconstructive tests were administered to three groups of schizophrenics who had undergone bilateral prefrontal leucotomy approximately 25 years earlier. A nonoperated schizophrenic patient group and a normal subject group served as controls for the effects of schizophrenic symptomatology and for age and education. The results demonstrated that orbital frontal white matter lesions do not disturb simple perceptions and constructions. The nonoperated schizophrenics had significant problems on many of the tests. Only one test, the WAIS Picture Arrangement, revealed deficits in all patient groups, including the good recovery leucotomized patients. This suggests impairment in the higher-order control and organization of perceptual material which may be secondary to orbital frontal white matter lesions or reflect aspects of the underlying schizophrenic disorder.

The involvement of orbitofrontal cerebrum in cognitive tasks.

Although the frontal lobes are frequently associated with high-level cognitive functions, patients with significant frontal damage often maintain normal "intelligence". While recent research has clarified some aspects of this enigma, specific questions remain concerning the nature of the deficit in these patients and its relation to lesion localization within the frontal lobes. A group of psychiatric patients who had undergone prefrontal leucotomy 25 years earlier and whose frontal lesions were bilateral and maximal orbitofrontally were evaluated. Sixteen leucotomized schizophrenics, divided into three groups based upon recovery after psychosurgery, were compared to two control groups: (1) non-leucotomized chronic schizophrenics; (2) normal subjects. Four tests were administered: Wechsler Adult Intelligence Scale, Wisconsin Card Sorting test, Visual Metaphor test, and the Visual Verbal test of abstraction. The results suggest that orbitofrontal pathology does cause impaired performance on certain cognitive tests, which appeared independent of IQ measures.

Evidence for the involvement of orbitofrontal cortex in memory functions: an interference effect.

Although it is frequently stated that the frontal lobes play a significant role in memory function, research proof has been ambiguous at best. This problem was addressed by administering a variety of memory tests to 16 schizophrenic patients who had undergone prefrontal leucotomy approximately 25 years earlier. The 16 were divided into three groups on the basis of recovery after surgery. Two comparison groups were established to control for psychiatric symptomatology, years of institutionalization, age, and years of education. The results demonstrate that large bilateral orbitofrontal lesions may not result in amnesia; in fact, the nonoperated schizophrenic control group performed the most poorly. Proactive interference was demonstrated, however, resulting in significant impairment for all patients with prefrontal lobe damage despite normal scores on commonly used memory tests. Ability to maintain consistent and directed attention and to overcome interference is proposed as a role of the frontal lobes in memory function.

Leucotomized and nonleucotomized schizophrenics: comparison on tests of attention.

Deficits in attention have been strongly linked with both schizophrenia and pathology in the prefrontal cortex. This observation was tested by administering a battery of commonly used tests of attention, sustained mental activity, and tracking to 16 patients who had undergone prefrontal leucotomy approximately 25 years earlier. Presurgical diagnosis in each patient was schizophrenia. The 16 were divided into three groups based on their recovery after surgery. A control group of nonleucotomized schizophrenics was established to control for psychiatric symptomatology. A second control group consisted of subjects without history of psychiatric or CNS disorder. In general, there was no statistically significant impairment of performance in attention tests between the patients with prefrontal psychosurgery and the normal control subjects. The nonoperated schizophrenic control group performed most poorly. Lesion chronicity, interaction of leucotomy and presurgical psychiatric state, and conditions of test administration are suggested as possible explanations for the unexpected results.

Long-term effects of prefrontal leucotomy--an overview of neuropsychologic residuals.

A battery of neuropsychologic tests was administered to 16 schizophrenics who had undergone prefrontal leucotomy approximately 25 years earlier. The 16 were divided into three groups based on their recovery after surgery. Five non-leucotomized chronic schizophrenics and five normal subjects served as controls. This paper presents a description of the subject population, a listing of the neuropsychologic battery administered, as well as main results from each major psychologic function tested. This information serves as an introduction and an overview for later detailed results.

The long-term effects of prefrontal leukotomy.

To explore the long-term effects of bilateral prefrontal destruction, 16 schizophrenics who had undergone prefrontal leukotomy approximately 25 years earlier were studied by neurologic examination, psychiatric outcome, EEG, computerized tomography (CT), and a battery of neuropsychological tests. Five nonleukotomized chronic schizophrenics and five age-matched normal subjects served as controls. We report details on the subjects, outline the test procedures, and offer an overview of the long-term residua. In general, the larger the frontal lesion demonstrated by CT, particularly if asymmetric, the better the psychiatric outcome and the better the performance on psychological testing, but there was no correlation between frontal lesion size and either neurological or EEG abnormality.

Frontal leukotomy size and hemispheric asymmetries on computerized tomographic scans of schizophrenics with variable recovery. Northampton Veterans Administration study.

The computerized tomographic (CT) scans of 17 schizophrenic men who had had bilateral prefrontal leukotomy performed 25 years earlier were examined to determine the relationship among leukotomy site, size, hemispheric asymmetries, and recovery. Six cases of good recovery (GR), five of moderate recovery (MR), and six of no recovery (NR) were studied; 16 of 17 patients were right-handed. Results showed that the GR cases had significantly larger lesions in the low orbitofrontal region (especially on the left) than did the other MR and NR cases. Also, five of six of the GR cases had significantly greater lesion size asymmetry in the low orbitofrontal region and overall than did the other MR and NR cases. There was no consistent asymmetry of lesion size (larger right or left) that was associated with recovery. Significant differences were observed in the hemispheric asymmetries of the right-handed schizophrenics vs normal subjects. Only half the cases had the expected increased left occipital width, and half had unexpected equal or increased right occipital widths. All of the GR cases had either an increased left or right occipital width; none had equal widths. Additional observation of long-standing leukotomy sites on CT scans in schizophrenia cases is recommended.