Families' experiences of the Low Arousal Approach: a qualitative study.

Background: Parents and carers supporting a family member presenting with behaviors of concern experience heightened stress. The Low Arousal Approach is a crisis management strategy which recognizes that stress, or physiological arousal, can be expressed through behaviors of concern. This approach aims to equip parents and carers to manage behaviors in a person-centered and non-confrontational way. There is a paucity of published research exploring the experiences of families applying this approach. Methods: Seventeen parents who had received training in the Low Arousal Approach were interviewed to gain their perspectives on supporting their family members using this approach. Results: Thematic analysis revealed themes relating to parental stress, which was related to external pressures, isolation, family stress, and challenges in their caring role. They described encountering negative narratives relating to self-criticism and negative judgments from others. Training in the Low Arousal Approach was related to being empowered through access to evidence, increased confidence, and increased ability to advocate for their family member's needs. Low Arousal was described as a "lifestyle" that enabled increased coping for the family unit as a whole. Discussion/conclusion: Findings indicate that it is vitally important to recognize the views of parents and carers, and these are equally as important as the views of professionals. We must understand parents' and carers' needs in order to provide adequate support.

Staff training in physical interventions: a literature review.

Background: Restrictive practices are used frequently by frontline staff in a variety of care contexts, including psychiatric hospitals, children's services, and support services for older adults and individuals with intellectual and developmental disabilities. Physical restraint has been associated with emotional harm, physical injury to staff and consumers, and has even resulted in death of individuals in care environments. Various interventions have been implemented within care settings with the intention of reducing instances of restraint. One of the most common interventions is staff training that includes some physical intervention skills to support staff to manage crisis situations. Despite physical intervention training being used widely in care services, there is little evidence to support the effectiveness and application of physical interventions. This review will examine the literature regarding outcomes of staff training in physical interventions across care sectors. Method: A systematic search was conducted following PRISMA guidelines using Cochrane Database, Medline EBSCO, Medline OVID, PsychINFO, and the Web of Science. Main search keywords were staff training, physical intervention, physical restraint. The MMAT was utilised to provide an analytical framework for the included studies. Results and discussion: Seventeen articles have been included in this literature review. The included studies take place in a range of care settings and comprise a wide range of outcomes and designs. The training programmes examined vary widely in their duration, course content, teaching methods, and extent to which physical skills are taught. Studies were of relatively poor quality. Many descriptions of training programmes did not clearly operationalise the knowledge and skills taught to staff. As such, it is difficult to compare course content across the studies. Few papers described physical interventions in sufficient detail. This review demonstrates that, although staff training is a 'first response' to managing health and safety in care settings, there is very little evidence to suggest that staff training in physical intervention skills leads to meaningful outcomes.

The Outsized Role of Salps in Carbon Export in the Subarctic Northeast Pacific Ocean.

Periodic blooms of salps (pelagic tunicates) can result in high export of organic matter, leading to an "outsized" role in the ocean's biological carbon pump (BCP). However, due to their episodic and patchy nature, salp blooms often go undetected and are rarely included in measurements or models of the BCP. We quantified salp-mediated export processes in the northeast subarctic Pacific Ocean in summer of 2018 during a bloom of Salpa aspera. Salps migrated from 300 to 750 m during the day into the upper 100 m at night. Salp fecal pellet production comprised up to 82% of the particulate organic carbon (POC) produced as fecal pellets by the entire epipelagic zooplankton community. Rapid sinking velocities of salp pellets (400-1,200 m d-1) and low microbial respiration rates on pellets (<1% of pellet C respired day-1) led to high salp pellet POC export from the euphotic zone-up to 48% of total sinking POC across the 100 m depth horizon. Salp active transport of carbon by diel vertical migration and carbon export from sinking salp carcasses was usually <10% of the total sinking POC flux. Salp-mediated export markedly increased BCP efficiency, increasing by 1.5-fold the proportion of net primary production exported as POC across the base of the euphotic zone and by 2.6-fold the proportion of this POC flux persisting 100 m below the euphotic zone. Salps have unique and important effects on ocean biogeochemistry and, especially in low flux settings, can dramatically increase BCP efficiency and thus carbon sequestration.

Elevated levels of hair cortisol concentrations in professional dementia caregivers.

Providing care for people with dementia can be a highly stressful profession. Hair Cortisol Concentration (HCC) levels have been used as a biological marker for HPA axis activity to demonstrate that informal caregivers of people with dementia could be vulnerable to chronic stress. The current study aimed to progress the findings of research conducted with informal caregivers and is the first study to assess HCC as a biological indicator of stress in professional carers of people with dementia. HCC levels were compared between 32 professional dementia caregivers (30 females with a mean age of 45.83 and 2 males with a mean age of 24.50), 45 employees working in higher education settings (42 females with a mean age of 38.66 and 3 males with a mean age of 31.89) and 88 undergraduate students (67 females with a mean age of 24.04 and 21 males with a mean age of 23.91). Analysis of HCC was used to assess HPA axis activity over 1 month. A one-way ANCOVA, with age and gender being included as covariates, revealed that higher levels of HCC were observed in professional dementia carers than people who worked within higher education settings and undergraduate students. The results indicated that professional dementia caregivers may experience stress to the extent of activating biological stress responses at a greater frequency in comparison to people who work in higher education and undergraduate students. However, no significant differences were observed in the perceived stress levels reported across dementia caregivers, professionals working in higher education, and undergraduate students. These findings highlight the requirement to ascertain the extent to which work-related tasks or other factors, specific to the profession of caring for people with dementia, could elicit heightened HPA stress reactivity.

Impact of a warm anomaly in the Pacific Arctic region derived from time-series export fluxes.

Unusually warm conditions recently observed in the Pacific Arctic region included a dramatic loss of sea ice cover and an enhanced inflow of warmer Pacific-derived waters. Moored sediment traps deployed at three biological hotspots of the Distributed Biological Observatory (DBO) during this anomalously warm period collected sinking particles nearly continuously from June 2017 to July 2019 in the northern Bering Sea (DBO2) and in the southern Chukchi Sea (DBO3), and from August 2018 to July 2019 in the northern Chukchi Sea (DBO4). Fluxes of living algal cells, chlorophyll a (chl a), total particulate matter (TPM), particulate organic carbon (POC), and zooplankton fecal pellets, along with zooplankton and meroplankton collected in the traps, were used to evaluate spatial and temporal variations in the development and composition of the phytoplankton and zooplankton communities in relation to sea ice cover and water temperature. The unprecedented sea ice loss of 2018 in the northern Bering Sea led to the export of a large bloom dominated by the exclusively pelagic diatoms Chaetoceros spp. at DBO2. Despite this intense bloom, early sea ice breakup resulted in shorter periods of enhanced chl a and diatom fluxes at all DBO sites, suggesting a weaker biological pump under reduced ice cover in the Pacific Arctic region, while the coincident increase or decrease in TPM and POC fluxes likely reflected variations in resuspension events. Meanwhile, the highest transport of warm Pacific waters during 2017-2018 led to a dominance of the small copepods Pseudocalanus at all sites. Whereas the export of ice-associated diatoms during 2019 suggested a return to more typical conditions in the northern Bering Sea, the impact on copepods persisted under the continuously enhanced transport of warm Pacific waters. Regardless, the biological pump remained strong on the shallow Pacific Arctic shelves.

A grounded theory study on work related stress in professionals who provide health & social care for people who exhibit behaviours that challenge.

Providing direct health and social care services for people who exhibit behaviours that challenge can be a highly stressful occupation. Existing literature has suggested that there is a need to develop further theoretical understanding of how work related stress can be reduced in professions that consist of providing care for people who exhibit behaviours that challenge. The aim for this study was to use a Classic Grounded Theory approach to develop a theoretical framework to illustrate a common issue that could influence work related stress levels experienced when managing behaviours that challenge in health and social care settings. A series of focus groups and 1:1 semi-structured interviews were conducted to explore the articulated experiences of 47 health/social care professionals who provide care for people who exhibit behaviours that challenge. This led to the development of Therapeutic Engagement Stress Theory (TEST), which illustrates that the perceived capacity to therapeutically engage with people who exhibit behaviours that challenge is an issue that can influence the levels of stress experienced by health/social care professionals. TEST provides a framework that could be applied to identify specific factors that inhibit staff to successfully deliver caring interventions for people who exhibit behaviours that challenge, and also inform bespoke support mechanisms to reduce stress in health/social care professionals.

Clinical holding: ethical guidance for children's nurses working in the UK.

This article explores ethical decision-making surrounding clinical holding of children and young people in healthcare environments with the aim of enhancing autonomy and engagement on their behalf. A considerable body of evidence, published over the last 20 years, suggests that this complex and challenging area of practice is not always well managed, with mixed messages about the nature of consent, choice and negotiated practice countered by best interests decisions taking precedence ahead of the child's wishes. An ethical framework is proposed comprising four levels of value-based interventions and how they may be applied in clinical practice, allowing for increased engagement, empowerment and support on behalf of children and young people in relation to clinical holding decisions.

Clinical holding with children who display behaviours that challenge.

Nurses hold children to administer treatment, prevent treatment interference and undertake clinical assessments, which can sometimes be invasive, as part of their regular duties. Clinical holding ensures this treatment or assessment is carried out safely, however, it has been reported that there is little training available in this area. This article explores the prevalent clinical holding techniques used by nursing staff when caring for children with behaviours that challenge. As an initial insight into what the researchers hope will become a more in-depth 2-year study, this investigation looks to explore current practice when holding children and the factors influencing this. It is hoped that this will inform the development of a training package offered to nurses when caring for these children. Thirteen semi-structured interviews took place with a small group of nurses, which were given thematic analysis. The overarching themes influencing holding practice were the nursing role itself along with intrinsic and external factors.

Holding children and young people: identifying a theory-practice gap.

Holding practices are employed to help a child or young person stay still during the administration of treatments, prevent treatment interference or to undertake an examination, which can sometimes be invasive. The aim of this study was to explore assumptions and practices of holding to develop theories about teaching practices following Grounded Theory methodology for undergraduate nursing students, university lecturers and clinical mentors. The practice of therapeutic holding is often covert and not considered to be part of the treatment per se, which has led to concealment and a reticence to discuss practices openly. This study identified that there is variance in the experiences and practices. Prominent themes that emerged were a lack of clarity and lack of training. It appears that therapeutic holding practices have moved from being viewed as 'uncontested' (practice is not disputed) to 'indifferent' (where there is denial about this practice). These findings have serious implications for current practice and future training.

The role of physiological arousal in the management of challenging behaviours in individuals with autistic spectrum disorders.

Challenging behaviours restrict opportunities and choices for people with autistic spectrum disorders (ASD) and frequently lead to inappropriate and costly service interventions. Managing challenging behaviours of people with autism is an important area of research. This paper examines some of the evidence for the role of physiological arousal influencing these behaviours. Evidence from the emerging literature about sensory differences is examined. It is proposed that sensory reactivity is associated with hyperarousal; catatonic type behaviours are associated with low levels of reactivity (hypoarousal). A low arousal approach is proposed as a generalised strategy to managing challenging behaviours with ASD. The use of non-contingent reinforcement and antecedent control strategies are recommended for use with challenging behaviours which have a sensory component. Examples are provided to illustrate the approach. The implications of arousal and the use of physical interventions are discussed. It is proposed that arousal is a construct which has significant heuristic value for researchers and practitioners.

Holding children and young people: defining skills for good practice.

Physical holds are used to help children and young people receive clinical care in situations where their behaviour may limit the ability of nurses and allied professionals to deliver treatment effectively. This article provides an overview of a qualitative study of 11 nurses and allied professionals who were interviewed with semi-structured questions. The major findings suggest there is a lack of clear and agreed terminology and nurses and allied professionals are guessing at how to describe the practice. As a result, there was no discussion or documentation of the practices of holding (whether successful or unsuccessful) within the clinical area. For the last decade, professional opinion was that this is an 'uncontested practice'. It can therefore be questioned whether this practice has moved from being 'uncontested' to 'indifferent'. Nurses and allied professionals need to revive a common definition of 'good' around the actions of holding, which can hopefully lead to holding skills being more clearly defined and evidence-based.

Pertactin beta-helix folding mechanism suggests common themes for the secretion and folding of autotransporter proteins.

Many virulence factors secreted from pathogenic Gram-negative bacteria are autotransporter proteins. The final step of autotransporter secretion is C --> N-terminal threading of the passenger domain through the outer membrane (OM), mediated by a cotranslated C-terminal porin domain. The native structure is formed only after this final secretion step, which requires neither ATP nor a proton gradient. Sequence analysis reveals that, despite size, sequence, and functional diversity among autotransporter passenger domains, >97% are predicted to form parallel beta-helices, indicating this structural topology may be important for secretion. We report the folding behavior of pertactin, an autotransporter passenger domain from Bordetella pertussis. The pertactin beta-helix folds reversibly in isolation, but folding is much slower than expected based on size and native-state topology. Surprisingly, pertactin is not prone to aggregation during folding, even though folding is extremely slow. Interestingly, equilibrium denaturation results in the formation of a partially folded structure, a stable core comprising the C-terminal half of the protein. Examination of the pertactin crystal structure does not reveal any obvious reason for the enhanced stability of the C terminus. In vivo, slow folding would prevent premature folding of the passenger domain in the periplasm, before OM secretion. Moreover, the extra stability of the C-terminal rungs of the beta-helix might serve as a template for the formation of native protein during OM secretion; hence, vectorial folding of the beta-helix could contribute to the energy-independent translocation mechanism. Coupled with the sequence analysis, the results presented here suggest a general mechanism for autotransporter secretion.

Fold recognition and accurate sequence-structure alignment of sequences directing beta-sheet proteins.

The ability to predict structure from sequence is particularly important for toxins, virulence factors, allergens, cytokines, and other proteins of public health importance. Many such functions are represented in the parallel beta-helix and beta-trefoil families. A method using pairwise beta-strand interaction probabilities coupled with evolutionary information represented by sequence profiles is developed to tackle these problems for the beta-helix and beta-trefoil folds. The algorithm BetaWrapPro employs a "wrapping" component that may capture folding processes with an initiation stage followed by processive interaction of the sequence with the already-formed motifs. BetaWrapPro outperforms all previous motif recognition programs for these folds, recognizing the beta-helix with 100% sensitivity and 99.7% specificity and the beta-trefoil with 100% sensitivity and 92.5% specificity, in crossvalidation on a database of all nonredundant known positive and negative examples of these fold classes in the PDB. It additionally aligns 88% of residues for the beta-helices and 86% for the beta-trefoils accurately (within four residues of the exact position) to the structural template, which is then used with the side-chain packing program SCWRL to produce 3D structure predictions. One striking result has been the prediction of an unexpected parallel beta-helix structure for a pollen allergen, and its recent confirmation through solution of its structure. A Web server running BetaWrapPro is available and outputs putative PDB-style coordinates for sequences predicted to form the target folds.