Biomedical subjects

L Bowers

Publications and source records attributed to L Bowers.

At least 19 recordsLinked to original sources

PubMed2006

Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses.

Acute psychiatric wards experience high levels of conflict behaviours (violence, absconding, self-harm, rule breaking and medication refusal) by patients. These events cause stress and injury to staff and patients. Their management through containment methods (e.g. sedation, restraint, seclusion) is contentious, and nurses are ambivalent about their use. The aim of this study was to reduce conflict and containment on two acute psychiatric wards through changes in nurses' beliefs, attitudes and practices. Two 'City Nurses' were employed to work with two acute wards for 1 year, assisting with the implementation of changes according to a working model of conflict and containment generation, itself based on previous research. Evaluation was via before-and-after measures. Statistically and clinically significant decreases in conflict occurred, with falls in aggression, absconding and self-harm. Ward atmosphere improved and nurse-patient interaction rates increased. There was no significant change in containment method use. Significant reductions in aggression, absconding and self-harm can be achieved on acute psychiatric wards. However, it does not appear that containment can be reduced, even through large reductions in conflict.

Attitude of Health Personnel↗

PubMed2006

Reflections on the process of change on acute psychiatric wards during the City Nurse Project.

The intention of this paper is to discuss the process of therapeutic change on two acute psychiatric wards during a research project that aimed to reduce conflict and containment. Analysis of fieldwork notes, reflection, team discussion and supervision. The City Nurse Project successfully reduced patient aggression, self-harm and absconding. This paper reports on the reflections made over the course of the year as changes and developments to acute wards took place. Specifically discussed are the beneficial effects of an action research approach, the role of the City Nurse, support for ward managers, education and training, clinical supervision as well as difficulties and barriers to the overall process of change. At an interim stage of the project, the staff have shown a willingness to engage in efforts to change and improve two acute wards. This paper shows the potential to improve acute wards and produce positive outcomes using a working model.

Behavior Control↗

PubMed2006

Constraints and blocks to change and improvement on acute psychiatric wards--lessons from the City Nurses project.

Recent years have seen sustained criticism and inspection of acute inpatient psychiatric wards, with the publication of reports and research leading to policy developments and a variety of efforts to improve perceived deficits. The City Nurses project seeks to reduce levels of conflict and containment on acute wards through the placement of expert nurses on wards to assist with the implementation of changes according to a working model of conflict and containment generation, based on previous research. Evaluation has shown significant decreases in aggression, absconding and self-harm by patients. However, in the course of working with the wards, various constraints and blocks to change have been identified and we describe these in detail in this paper. Analysis of the fieldwork diaries of the two City Nurses identified that change was hindered by limited staffing resources, problems with the physical environment and other resources, insufficient beds and the process of bed management, hierarchical ambiguity and multidisciplinary issues, the overdemanding role of the ward manager, and pervasive anxiety about the potential for serious untoward incidents and their implications for staff. We argue that sustained positive change in acute inpatient psychiatry requires these underlying structural issues to be both acknowledged and, if possible, resolved.

Acute Disease↗

PubMed2006

An analysis of nurses' post-incident manual restraint reports.

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

Aggression↗

PubMed2005

Training in cognitive behavioural interventions on acute psychiatric inpatient wards.

There has been a drive towards addressing the types of care and therapeutic interventions available to people with serious mental illness, which is reflected in the latest government mental health policy initiatives. Recent evidence strongly supports the implementation of psychological and social interventions for people with psychosis, and in particular the use of cognitive behavioural techniques. Until now, the main focus has been on people living in the community. This study examines the delivery of psychosocial interventions training to qualified psychiatric nurses and unqualified staff on seven acute psychiatric admission wards in London, UK. The approach had the strength of on-site delivery, follow-up role modelling of the interventions and clinical supervision. Despite this, in some cases the training was less successful, mainly because of staffing and leadership weaknesses. The impact of training in these methods and the implications for mental health education and practice development are discussed.

Acute Disease↗

PubMed2005

Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing.

The purpose of acute inpatient psychiatric care, and nurses' role within that, are in need of clarification and restatement in order to provide a framework for practice, education, research and development. Inpatient psychiatry has suffered from a paucity of research in recent years. In addition, being a complex system, involving multiple professions with differing ideologies, means that widely accepted succinct descriptions of its purpose are hard to achieve. Yet such a framework is essential to support positive attitudes to patients and for good staff-management relationships. Using an oblique strategy, this paper defines the function of acute inpatient psychiatry, and the role of psychiatric nurses, via a structured examination of the literature on reasons for admission to acute inpatient psychiatric wards. Seven such reasons were discovered and are described: dangerousness, assessment, medical treatment, severe mental disorder, self-care deficits, respite for carers, and respite for the patient. Acute inpatient psychiatric nurses are therefore: providing safety for the patient and others; collecting and communicating information about patients, giving and monitoring treatment; tolerating and managing disturbed behaviour; providing personal care; and managing an environment where patients can comfortably stay. The implications for psychiatric nursing are discussed.

Acute Disease↗

PubMed2005

Real world application of an intervention to reduce absconding.

Absconding by acute psychiatric inpatients is associated with risk of harm to self and others, and creates considerable emotional as well as tangible burdens for staff. Previous research has led to the development of an effective nursing intervention to reduce absconding. In this project, that intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can be made in absconding rates from unlocked or partially locked acute psychiatric wards.

Attitude of Health Personnel↗

PubMed2005

Coercive manoeuvres in a psychiatric intensive care unit.

Coercive manoeuvres in a psychiatric intensive care unit The practice of physical restraint techniques in the management of disturbed behaviour is a significant part of the role of mental health nurses, particularly in Psychiatric Intensive Care Units (PICUs). Debate about what constitutes good practice is intense, and the subject of recently issued guidelines by National Institute for Mental Health in England. However, the contribution of other forms of conflict management techniques has tended to be ignored. The purpose of this study was to identify, describe and categorize coercive manoeuvres used by nurses, and to examine the circumstances and appropriateness of their use. Non-participant observation of verbal and non-verbal interaction between patients and nurses during conflict situations was undertaken on one PICU. The critical incidents observed were identified, categorized and systematically recorded. Nurses used a variety of low level physical and interactional manoeuvres in order to manage patients' disturbed and resistive behaviour. These manoeuvres were seldom recorded, discussed or reviewed, although they were frequently used to manage critical conflict situations. These manoeuvres have neither been previously described nor evaluated. They may, in some cases, be useful substitutes for actual restraint, alternatively they may, in some cases, be judged undesirable. It is not known how widespread these practices are in acute psychiatry.

Coercion↗

PubMed2004

Acute psychiatric ward rules: a review of the literature.

This literature review forms a background element of a comparative study of two acute psychiatric wards in the East End of London. The research focused on ward rules as a means of investigating the relationship between the flexibility/inflexibility of ward nursing regimes and patient outcomes. Previous studies identified a relationship between ward rules and patient aggression. Other studies identified a link between absconding by inpatients and nurses' attitudes towards rule enforcement. However, an in-depth exploration of psychiatric ward rules from the perspective of nurses and patients has not been undertaken previously.

Attitude of Health Personnel↗

PubMed2003

A review of research on the structure, process and outcome of liaison mental health services.

Liaison mental health services (LMHS) developed originally to address the mental health needs of people with physical illnesses in general hospitals and more recently to work also with people with mental health problems presenting at non-mental health services. The purpose of the present paper was to review empirical research on the structure, process and outcome of liaison mental health services using systematic review methods. Following a comprehensive search strategy, the authors reviewed 48 papers published between 1975 and 2001. There is an extensive international literature on LMHS, much of which describes the structure and process of liaison work. Studies evaluating the outcomes of liaison mental health services are fewer, and handicapped by methodological flaws, some of which are serious enough to cast doubts on the reported results. Professionals and clients value LMHS. LMHS based in accident and emergency (A & E) departments appear to ease the burden of general A & E staff, help clients access mental health services and reduce re-admission rates of people with mental health problems. There is little evidence supporting one model of configuring LMHS over another.

Emergency Service, Hospital↗

PubMed2003

Manipulation: description, identification and ambiguity.

The word manipulation is frequently applied to some of the difficult-to-manage behaviours of the personality-disordered patient. However, the term is rarely defined, and a review of both the clinical and research literature shows that little has been written about its definition and identification, let alone its clinical management in both in- and outpatient settings. Recent empirical work conducted with nurses in forensic settings has demonstrated the range of behaviours that professionals refer to as 'manipulative', thus clarifying the use of the term and allowing the provision of a more precise definition. The scope of manipulation in everyday life, management practice and politics is perhaps relatively small, although manipulation can occur in all areas of human activity. Social behaviour is doubly ambiguous with respect to judgements of manipulation, as such judgements involve a moral evaluation combined with the identification of deception on the basis of little or partial evidence. The implications of this social ambiguity for clinical psychiatric practice are that professionals need to guard themselves from two polar faults: seeing manipulation everywhere; or being blind to its presence. In order to achieve a cautious moderation, staff need to hold both alternatives in mind at all times.

Attitude of Health Personnel↗

PubMed2003

Manipulation: searching for an understanding.

Manipulative behaviour is one of the reasons why some psychiatric professionals dislike personality-disordered (PD) patients and dislike working with them. Being manipulated arouses strong negative emotions towards the manipulator and can have severe repercussions on the ability to care for or treat those suffering from personality disorders. In order for practitioners to cope with manipulative behaviour and manage their emotional responses towards it, it is necessary to find ways to understand or construe that behaviour, so that moral condemnation and rejection of the patient can be avoided. This article offers a summary of three such methods of interpreting manipulation which are to be found in the literature: manipulation as normal behaviour; manipulation as unconsciously motivated; and manipulation as cognitive distortion. These three viable schemes for the understanding of manipulation provide not just a means to enable a non-judgmental approach, they also provide ways to manage that behaviour in a therapeutic manner.

Attitude of Health Personnel↗

PubMed2003

A trial of an anti-absconding intervention in acute psychiatric wards.

Absconding from acute psychiatric wards is a significant clinical problem that can place patients and others at risk, as well as being burdensome and anxiety provoking for staff. Previous studies have not convincingly demonstrated the best way to minimize the frequency of absconding. The aim of this trial was to evaluate the impact of an intervention to reduce absconding by patients from partially locked acute psychiatric wards. Five acute psychiatric wards in one hospital were entered into a stepped, before-and-after controlled trial. Following 3 months at baseline, nursing staff on the wards were trained in the intervention and monitored in its execution for the next 3 months. Absconding and violent incidents were recorded by nursing staff through shift reports and validated against officially collected forms. Absconding reduced by 25% overall during the intervention period, a fall which was statistically significant. Three out of the five wards implemented the intervention effectively and two of these achieved decreases in their absconding. The other two wards were not able to consistently implement the intervention, and their absconding rates remained unchanged. The findings support the efficacy of the intervention in reducing absconding. Further research is now required to replicate these findings, and to confirm that any reductions are maintained over time.

Adult↗

PubMed2003

Case management models and the care programme approach: how to make the CPA effective and credible.

The care programme approach (CPA), a form of case management, is a key mental health policy in England. Yet after over 10 years, it remains poorly and unevenly implemented with few benefits for service users, carers or mental health staff. This paper reviews the wider literature on case management and identifies and considers the principal models that might have informed the development of the CPA. After discussing the evidence for each of the clinical, strengths, intensive and assertive case management models, the paper identifies the key components that appear to be central to effective case management across these models. These components are then considered in relation to the CPA. It is argued that the CPA has been undermined by a failure to incorporate and build on certain important features of the major models of case management. The paper concludes by suggesting the key developments required to make the CPA more effective and to underpin the policy with a unifying philosophy while endorsing it with much needed credibility among both clinicians and service users.

Attitude of Health Personnel↗

PubMed2002

Issues in the measurement of violent incidents and the introduction of a new scale: the 'attacks' (attempted and actual assault scale).

OBJECTIVE: To review the strengths and weaknesses of existing violent incident measures, and introduce a new scale, the 'attacks'. The new scale provides an objective measure of incident severity and focuses on interpersonal physical violence in isolation from other behaviours. METHOD: The new scale was piloted on six psychiatric wards in the East End of London over a period of 16 weeks. Descriptive data were obtained and validated against official violent incident records. RESULTS: There were 40 incidents by 21 aggressive patients, most of which occurred on the psychiatric intensive care unit. Striking assaults predominated. Continuous holding of the patient by nurses occurred after 17% of incidents. Special observation was also used as a subsequent management method in more than half of the incidents. CONCLUSION: The scale is acceptable to nurses and valid. Interesting questions are raised about the content of training for staff in the prevention and management of violent incidents.

Adult↗

PubMed2002

An audit of referrals of children with autistic spectrum disorder to the dietetic service.

UNLABELLED: Autistic spectrum disorder (ASD) is a developing area for dietetic referrals. There is little published data on current dietetic practice. Some children with ASD are referred for gluten/casein free diet. The theory is that abnormal metabolites in the urine may be a result of incomplete breakdown of gluten and casein in the gut. There are some published open studies that support the efficiency of such a diet [Knivsberg et al. (1995) Scand. J. Educ. Res.39: 223; Lucarelli et al. (1995) Panminerva Med.37: 137; Whiteley et al. (1999) Int. J. Res. Practice 3: 45] and also that there are many anecdotal reports that the diet helps some children. AIMS AND OBJECTIVES: This study aimed to audit the types of referral made to the dietetic service to identify key dietetic issues and to describe factors which may influence outcome/disease management. METHODS: Dietetic records were used to audit the referrals to the dietetic service over a 3-month period. Seven-day diet histories were assessed using computer food composition tables and topics of interest recorded against a draft protocol agreed within the profession. RESULTS: Requests for gluten-free and casein-free dietetic advice, and/or the management of food selectivity and dysfunctional feeding behaviour constituted the majority of referrals. In many cases, child's environment was rarely simple. CONCLUSIONS: Despite the limitations of this small study, the findings suggest that the management of these referrals is highly complex. A dietitian's input should ensure that the nutritional adequacy of the diet is maintained or restored.

Autistic Disorder↗

PubMed2002

Safety and security policies on psychiatric acute admission wards: results from a London-wide survey.

Very little research evidence is available regarding current safety and security procedures on acute psychiatric wards. This includes controversial areas such as the temporary removal of personal property, the searching of patients and visitors, the use of alarms and modern technology, and locking of entrances to regulate those entering and leaving. This is also despite widening dismay over increasing violence within a variety of hospital settings, the comparatively high risk of physical assault faced by mental health professionals and an abundance of literature and training in regards to violence management and prevention. To gain an understanding of current safety and security measures, a London-wide survey of acute admission wards was undertaken revealing a wide variety of measures and policies in operation. Over 100 NHS and private wards were sent questionnaires; there was a response rate of 70%. Results show that a significant proportion of acute admission wards are now locked at all times and a small proportion of units have 24-hour security/reception staff on-site and a low level of modern technology usage such as CCTV and electronic access systems. There is wide variation in items banned, restrictions placed on inpatients, and the searching of patients and visitors. Two independently varying emphases of ward security policies were identifiable, the first aimed at preventing harm to patients using door security, banning of item and restrictions on inpatients. The other is aimed at reducing risks to staff via searching of patients, use of security guards and sophisticated alarm systems. There is some preliminary evidence that these security policies are differentially associated with levels of absconding and violent incidents. Further research to guide practice is urgently required.

Admitting Department, Hospital↗

PubMed2002

Philosophy, care and treatment on the psychiatric intensive care unit: themes, trends and future practice.

Psychiatric intensive care units (PICUs) were first developed in the UK in the early 1970s and have become an integral part of inpatient services. This paper reviews all aspects of PICU provision from its origins to the most recent studies of intensive care treatment and philosophy. A search of CINAHL, MEDLINE and British Nursing Index databases revealed ample research and discussion papers from the past 30 years to permit a thorough review of the available literature. This divides roughly into discussion and descriptive research on topics related to: (a) the infrastructure of PICUs, including bed numbers, staffing levels, admission criteria and aspects of the physical environment; and (b) the treatment provided to patients on the PICU, both pharmacological and psychosocial, plus a limited amount of evaluative research on the efficacy of PICU care. This paper provides a summary and overview of these issues based upon currently available literature. It concludes that there is strong evidence for wide variation in the provision and nature of PICU care, reflecting idiosyncratic and localized development of services. Moreover, there is an almost complete lack of evidence on the efficacy of PICU care for particular types of patients and problems, leaving a paucity of research upon which PICU infrastructure, policy and therapeutic approach can be based.

Ethics, Clinical↗