Implementation of Simulation: A Contemporary Strategy to Enhance Clinical Skills of Undergraduate Students in Mental Health Nursing.

Simulation is an innovative teaching strategy that supports student centered learning. It improves therapeutic communication skills with clients. Additionally, it enhances critical thinking, problem solving, and confidence among students, in a non-threatening and safe environment, without posing a risk to actual patients. This paper describes the process of application of simulation for undergraduate nursing students enrolled in a mental health nursing course. The project aimed to determine the significance of simulation to improve the communication skills and confidence level, and to decrease the anxiety of undergraduate nursing students, prior to attending mental health clinical. The Experiential Learning (ELT), by Kolb in 1984, was chosen as a framework for the simulation strategy. The simulation experience was a stepwise process that comprised a briefing session with students to explain them the process and purpose of the simulation activity, followed by a two-day simulation experience. The experience comprised students' interaction with Simulated Patients (SP), who had been prepared to manifest symptoms of depression, mania, and schizophrenia. The later part of the experience was a debriefing session, in which students were provided an opportunity for self-reflection and for thinking a way forward, to enhance their clinical competency, using their video recording. The students' evaluation regarding the simulation experience was positive and they suggested that it be integrated in the mental health nursing course.

Toxicological evaluation of a saponin-rich standardized extract of fenugreek seeds (FenuSMART®): Acute, sub-chronic and genotoxicity studies.

The present study investigated the safety of a saponin-rich standardized extract of fenugreek seeds (FenuSMART®; FHE), that has been clinically shown to be effective in ameliorating the postmenopausal discomforts and establishing hormonal balance. The safety was assessed by oral acute (2500 mg/kg b. wt. for 14 days) and subchronic (250, 500 and 1000 mg/kg b. wt. for 90 days) toxicity studies on Wistar rats and mutagenicity studies employing Salmonella typhimurium strains. Administration of FHE did not produce any toxicologically significant changes in clinical/behavioral observations, ophthalmic examinations, body weight, organ weight, feed consumption, urinalysis, hematology and clinical biochemistry parameters when compared to the untreated control group of animals. Highest dose recovery group (1000 mg/kg b. wt.) of animals also showed no mortality or adverse events; with hematological and biochemical parameters at par with those of controls. Terminal autopsy revealed no alterations in relative organ weight or any treatment-related histopathology changes. FHE also showed no mutagenicity upon Ames test employing TA-98, TA-100 and TA-102 Salmonella typhimurium strains with or without metabolic activation. Based on the results of the study, the no observed-adverse-effect level (NOAEL) of FHE was determined as 1000 mg/kg b. wt./day, the highest dose tested.

Treatment compliance and noncompliance in psychoses.

BACKGROUND: Compliance or noncompliance with treatment significantly influences course and outcome of psychiatric disorders. While noncompliance has been extensively researched, compliance has received less attention. The current study was conducted to elicit reasons for compliance and noncompliance in patients having psychoses attending psychiatric clinics. MATERIALS AND METHODS: A total of 196 compliant and 150 noncompliant patients were interviewed using self-designed tools to elicit sociodemographic data, details of illness, and treatment. Factors contributing to compliance and noncompliance were grouped under illness-related, clinician-related, medication-related, family-related, and economic-related domains and compared. RESULTS: Compliance was significantly more in females and middle- and high-socioeconomic status patients. They had less substance use, high physical comorbidity, high attendance in the outpatient department, and better remission. Clinician-related, family-related, and medication-related domains were contributing more to compliance whereas illness-related and economic-related domains seemed to have more bearing on noncompliance. CONCLUSIONS: Compliance and noncompliance are determined multidimensionally. Domains related to clinician, family, and medications have to be reinforced to enhance compliance. Illness-related and economic domains have to be resolved to reduce noncompliance.

Comorbidity of psychiatric and personality disorders in first suicide attempters: a case-control study.

OBJECTIVES: Comorbid psychiatric and personality disorders in suicide attempters pose greater estimated risk of suicide than psychiatric disorders alone. The current study aimed to evaluate prevalence and pattern of psychiatric and/or personality morbidity and comorbidity in first-time suicide attempters in comparison to the age and sex matched community sample. METHODS: Socio-demographic variables, family background, psychiatric morbidity and comorbidity in survivors of first suicide attempt were compared to age and sex matched community controls. Structured (Mini International Neuropsychiatric Interview plus) and semi-structured (International Personality Disorder Examination) clinical interviews were utilized to evaluate for axis-I and axis-II (personality) diagnosis. Risk-rescue rating was administered to assess medical seriousness of suicide attempt. RESULTS: Individuals who made a first suicide attempt showed significantly lower educational achievement (P<0.0001; OR 1.56; 95% CI 0.89-2.74), but no significant difference in other socio-demographic variables compared to the controls. Cases had high family history of psychiatric illnesses (31% vs. 7%; P<0.0001; OR 5.97; 95% CI 2.48-14.35); high prevalence of psychiatric disorders (89% vs. 25%; P<0.0001; OR 24.27 95% CI 11.21-52.57), personality disorders (52% vs. 24%; P<0.0001; OR 3.43; 95% CI 1.88-6.28), comorbidity of psychiatric and personality disorders (51.6% vs. 19.5%; P=0.022; OR 3.01; 95% CI 1.14-7.92), and high overall prevalence of any axis-I and/or axis-II (personality) morbidity (93% vs. 41%; P<0.0001; OR 19.12; 95% CI 8.05-45.43), compared to controls. CONCLUSION: Survivors of first suicide attempt are at nineteen times increased odds of having psychiatric morbidity and/or comorbidity, especially with personality disorders. Personality evaluation and management in such individuals may result in better comprehensive approach to health care.

Comorbidity of psychiatric and personality disorders in first suicide attempters.

BACKGROUND: Attempted suicide is a common clinical problem in a general hospital setting. It has a serious clinical and socio-economical impact too. AIMS: To study the psychosocial, psychiatric, and personality profile of the first suicide attempters in a general hospital. SETTINGS AND DESIGN: Cross-sectional, hospital-based, descriptive study. MATERIALS AND METHODS: All the consecutive cases of first suicide attempt (n=100) treated in a general hospital were studied to know the clinical profile. Variables related to socio-demographic characteristics, family background, suicide characteristics, psychiatric morbidity, and comorbidity were analyzed. Risk-Rescue rating was applied to know the medical seriousness of the suicide attempt. Presumptive stressful life event scale was utilized to calculate life events score. Structured clinical interview (MINI Plus) and semi-structured clinical interview (IPDE) were used for axis-I and axis-II (personality) diagnoses. The results were analyzed using appropriate statistical measures. RESULTS: Family history of psychiatric illnesses (31%) and suicide (11%) were noted. Insecticides and pesticides were the most common agents (71%) employed to attempt suicide. Interpersonal difficulties (46%) were the most frequent stressor. Overall medical seriousness of the suicide attempt was of moderate lethality. 93% of the suicide attempters had at least one axis-I and/or axis-II psychiatric disorder. Most common diagnostic categories were mood disorders, adjustment disorders, and substance-related disorders, with axis-I disorders (89%), personality disorders (52%), and comorbidity of psychiatric disorders (51.6%). CONCLUSION: Individuals who made first suicide attempt were young adults, had lower educational achievement; overall seriousness of the suicide attempt was of moderate lethality, high prevalence of psychiatric morbidity, personality disorders, and comorbidity, and had sought medical help from general practitioners.

Ray of hope: opportunities for reducing unsafe abortions!

Unsafe abortion is one of the leading causes of maternal mortality and morbidity which impede the nation in achieving the targets of MDG 5. In the developing world, it is estimated that 13% of all maternal deaths are due to unsafe abortions. Despite having certain liberty in the law and religion, Pakistan has a relatively high prevalence of unsafe abortion. Poverty, unintended pregnancies, ineffective use of contraceptive methods and unawareness about the law are the root causes for the rise in the number of women seeking abortions. Nonetheless, with all these opening points of having permission in the law and religion could direct us that if we just follow them we can reduce the number of unsafe and illegal abortions.Therefore, there is a strong interventions would be required in health and legal aspects, which would decrease maternal mortality and morbidity.

Perceptions of "caring" in nursing education by Pakistani nursing students: an exploratory study.

INTRODUCTION: Caring is considered to be a highly abstract concept. Nurturing a caring attitude in nursing education is important as this is the first place for students to learn about the most significant values and essence of their profession. AIM: The aim of the study was to describe the concept of caring from the perspective of nursing students. METHODOLOGY: An exploratory research design was utilised for this study. Eight senior nursing students from one government institute (College of Nursing) in X country were recruited as study participants. Data was generated through in-depth one-to-one interviews and analysed using Creswell's six-step guide for qualitative data analysis. The interviews were tape recorded and a "member check" technique was used. FINDINGS: The study results found the themes of caring as a mothering relationship, helping attitude, limit setting, communication, and a source of empowerment and development. CONCLUSION: The implications of the findings for nursing education, faculty development, and research are described in the study.

Media created violence: a social determinant of mental health.

In today's high technological world, scientific discoveries contribute remarkable development to human life, but it could also have an adverse impact on mankind. Among all these advancements, media is one of the inventions which aims at capturing a countless group of viewers and transmit information via various mediums. Media violence is considered one of the hampering determinants which harms an individual psychologically. The primary goal of a health professional is to work for the maintenance of mental health. Therefore, it is imperative to create an understanding about the impact of media violence on mental health, particularly in the Pakistani context. Violence has become a major public health problem in Pakistan. The main cause of violence seems to be anger and frustration due to poverty, political conflicts, lack of education, and the overall governance approach in the country. Therefore, there is a prime need to think and work on this neglected area like conducting research and increasing public awareness, and to curb media violence.

Validity of screening tools for emotional problems in school children.

BACKGROUND: Emotional problems in school children may result in low level of scholastic performance. The recognition of these disorders needs effective screening tools. The choice lies between self assessment tools or observation based tools. Majority of studies use screening tools based on parental or teachers' observation. AIM: This study was designed to compare a self-assessment based screening tool (general health questionnaire; GHQ) with a parental observation based screening tool (CPMS-Childhood Psychopathology Measurement Schedule). MATERIALS AND METHODS: Two hundred and eighteen school children were selected through multistage random sampling. The study was conducted in three stages. In the first stage, all the students were administered six-item version of GHQ to screen for emotional problems. Raven's Progressive Matrices was administered to evaluate IQ. In the second stage, parents assessed their child's behavior using CPMS. In the third stage, all students were subjected for detailed clinical work-up. STATISTICAL ANALYSIS: Criterion validity of the tools used and their comparison. RESULT: GHQ had high sensitivity and specificity compared to CPMS in relation to clinical interview. CONCLUSION: It is found that GHQ is a better screening tool than CPMS in children aged between 13 and 14 years.

Self-injurious behavior: A clinical appraisal.

A case series of self-injurious behavior (SIB) encountered in a General Hospital setting has been described. Limitations of current definition of SIB are explained. SIB is not a single clinical entity and it occurs in various psychiatric syndromes with wide range of psychopathology. Based on clinical criteria, a classification of SIB into three groups has been proposed viz 1) Mild and isolated form, 2) Moderately severe and repetitive form, and 3) Very severe and isolated form. Psychodynamic, cognitive and neurochemical explanations of SIB have been reviewed. Frustration, aggression and impulsivity appearing in helpless situation appear to be a common script across most of these models of explanations. Severity of injury seems to be determined by severity of psychopathology. Site of injury appear to have symbolic significance for a particular patient. Understanding some of these clinicopsychopathological issues helps in management of these cases.

Audit of leiomyoma uterus at Khyber teaching hospital Peshawar.

BACKGROUND: Fibroid is the commonest tumor of the reproductive tract and frequently encountered problem in gynecological practice. This study was carried out to observe the frequency of fibroids in relation to age, parity and clinical manifestations along with a critical review of its management. METHODS: This study was carried out over a period of one year from 1st January to 31st December 2000 in Gynae "A" unit of Khyber teaching hospital, Peshawar. All patients presenting with fibroid uterus were included in the study. Data collection included age, parity, menstrual pattern, presenting symptoms, medical and surgical treatment history. Diagnostic criteria were clinical and ultrasonography. Evaluation of medical treatment and surgery were carried out. Management outcome of minimal invasive surgery was also observed. RESULTS AND CONCLUSION: Total 146 cases were observed. Greater frequency was found in late reproductive and perimenopausal years (65.7%). There were 34.2% cases in reproductive age group. Majority was multiparous (72%) and 28% were nulliparous. Infertility was noticed in 16%. Myomas were mostly symptomatic (70%). Menstrual symptoms were commonest (81.5%), pain was second common symptom (27.3%). About 24% presented with abdominal mass and hyaline degeneration were in 50% of cases. Leiomyomas were multiple in 63.1% and commonest variety was interstitial (60.4%). Familial factor noticed in 5.4%, clinical diagnosis was made in 58.2% of cases, while ultrasound was used in 40.4% of patients, conservative treatment was given in 37.6% including medical therapy (8.2%). Surgery was performed in (62.3%). Myomectomy (10.2%) and hysterectomy was carried out in 52.05%. Minimal invasive surgery was not possible in our set up.

Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors.

BACKGROUND: All pregnant women are at risk of obstetrical complications and most of these occur during labour and delivery that lead to maternal death. In our setup maternal mortality is seriously under estimated. Safe motherhood as a priority for action can not be identified with out properly assessing maternal mortality. The objectives of this study were to determine causes and preventable factors responsible for maternal mortality. METHODS: This study was conducted in Gynaecology 'C' unit of Ayub Teaching Hospital, Abbottabad, from January 2000 to December 2001. Patients were admitted through emergency obstetrics care unit and Gynaecology out patient department. Patients' demographic record including age, parity, education, socio-economic status along with antenatal care record, level of care and distance from hospital were noted. Causative factors leading to maternal death and contribution factors evaluated. All this information was collected from patients' records. RESULTS: Twenty-six maternal deaths were recorded during study period. The major causative factors were haemorrhage 9 (34.6%), eclampsia 8 (30%), sepsis 5 (19.2%), anaesthetic complications 3 (11.5%) and hepatic encephalopathy 1 (3.8%). Maternal mortality ratio was 12.7/1000 live births (26/2040). The age range was between 18-42 years. There were 16 (61.5%) patients in > 30 years age group. Most of them (69%) were grand multiparas (Parity > 5). Education, antenatal booking and socio-economic status were poor. The distance from hospital was between 10 and 100 KM. The level of care available at nearest health facility was estimated, 40% were attended by traditional birth attendants, 33% by lady health visitors, 10% by doctors and to 17% no level of care was available. CONCLUSION: Obstetrical haemorrhage and hypertensive disorders are still major causes of maternal deaths. Most maternal deaths are preventable. The provision of skilled care and timely management of complications can lower maternal mortality in our setup.

Minilaparotomy and ovarian diathermy drilling for clomiphene resistant poly cystic ovarian disease.

BACKGROUND: This study was carried out to determine the effectiveness and safety of minilaparotomy and ovarian drilling for sub fertile women with clomiphene resistant polycystic ovarian syndrome. METHODS: During a 2 year period (August 2000 to August 2002) 16 patients with polycystic ovarian disease were managed by minilaparotomy and ovarian drilling by diathermy. All the patients underwent full infertility workup and then treated with cyclical clomiphene citrate for 6 months. RESULTS: Six patients (37.5%) presented in age group 15-25 years. Eight patients (50.0%) were in age group 26-35 years. Only 2 (12.5%) patients presented in age group 36-44 years. Eleven (68.75%) patients had primary infertility. Five (31.25%) patients presented with secondary infertility. After treatment and 6 months follow up, ovulation occurred in 14 (87.5%) patients. Eleven (68.75%) women conceived pregnancy. CONCLUSION: Ovarian drilling is a powerful tool in the treatment of polycystic ovarian disease.

Uterine rupture: a review of 34 cases at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Uterine rupture is a deadly obstetrical emergency endangering the life of both mother and fetus. This descriptive study was conducted to determine the frequency of ruptured uterus at Ayub Teaching Hospital Abbottabad and to elicit possible causes/reasons of ruptured uterus. METHODS: The study was conducted at the department of Obstetrics & Gynaecology, Ayub Teaching Hospital, Abbottabad, Pakistan over a period of one year from July 1st, 2001 to June 30th, 2002. All cases of uterine rupture presenting during the study period were recorded and managed in the department using a protocol prepared for the purpose of this study. Data was recorded on pre-designed Proforma. RESULTS: There were 34 cases of ruptured uterus out of a total of 3435 deliveries (including 1128 Caesarian sections) over a one-year time period (incidence of 1/100 deliveries) with 31 intra-partum deaths. The most common age group was from 31-35 years (16/34, 47%), followed by the 26-30 years age group (13/34, 38.2%). A majority (29/34, 85.3%) were cases of unscarred uterus presenting with rupture; the most common cause of rupture in all cases was inappropriate injections of Oxytocin (11/34, 32.35%), followed by obstructed labour (9/34, 26.5%). All were anemic and most of them were in shock. CONCLUSION: The leading cause of ruptured uterus was found to be mismanagement by traditional birth attendants. We can reduce maternal mortality due to rupture uterus by giving proper training to traditional birth attendants and by mass education through electronic media.