Advances in geropsychiatric nursing: A decade in review.

This article provides a brief overview of the early development of geropsychiatric nursing (GPN) as background for examining its advancement subsequent to the 2010 Future of Nursing (FON) Report. The FON's education, practice and leadership recommendations form the three pillars that have supported geropsychiatric nursing's continuing evolution, framed within a practice and policy perspective. Lessons learned are relevant to developing the next phase of FON recommendations. The importance of overcoming challenges faced by the field of GPN is supported by the aging global population, the directions of nursing as a discipline, and the clear necessity of an intra- and inter-professional approach to mental health and aging.

Depressive symptoms in caregivers immediately after stroke.

BACKGROUND: Caregivers of stroke survivors often suffer depressive symptoms that interfere with their own health. Early recognition may lead to attenuation of symptoms and better health and well-being for caregivers. OBJECTIVE: We examined characteristics of caregivers and stroke survivors associated with caregivers' depressive symptoms in the early poststroke period. METHODS: We conducted a prospective, longitudinal exploratory observational study with a convenience sample of 63 caregivers of older adult (≥ 65 years) stroke survivors recruited from urban acute-care settings. We enrolled caregivers by 2 weeks poststroke (T1) and revisited them 4 weeks later (T2). Depressive symptoms were measured using the Patient Health Questionnaire-9. A separate unadjusted linear mixed model was computed to explore significant associations between each caregiver or stroke-survivor characteristic and depressive symptoms. RESULTS: Caregivers, on average, reported mild depressive symptoms at T1 and T2. Each of the following characteristics was independently associated with caregiver depressive symptoms over the first 6 weeks poststroke: caregiver uncertainty (p < 0.001), perceived stress (p < 0.001) but not cortisol levels (p = 0.858 on waking, p = 0.231 evening), coping (p < 0.001), social support (p = 0.006), race (p = 0.022), income (p = 0.001), time spent on care (p = 0.039), and stroke-survivor race (p = 0.033) and functional status (p = 0.003). At T2, caregiver depressive symptoms were correlated with evening cortisol level (p = 0.001). CONCLUSIONS: Caregiver and stroke-survivor characteristics may help identify caregivers at highest risk for early depressive symptoms and guide interventions aimed at their resolution.

Professional networks and support for nursing home directors of nursing.

In this study, we examined the influence of professional network characteristics, available professional support, and perceived support quality on intent to stay among for-profit nursing home (NH) directors of nursing (DON). We hypothesized that the receipt of high quality professional support would be associated with DON intent to stay. DONs have a critical mandate to provide leadership that influences their facilities' work climate and care quality. Yet, they often struggle to manage overwhelming responsibilities and are left feeling alienated, frustrated, and intent on leaving their jobs. Professional support, accessed via professional networks, may help DONs combat frustration and mitigate turnover that threatens NH care quality. Using a descriptive survey design, we electronically surveyed all DONs employed by a single for-profit NH corporation to collect data pertaining to their professional networks, receipt of professional support, perceptions regarding support quality, and intentions to stay in their positions. One-hundred-ninety-five DONs (65%) responded, with 133 (44%) completing every survey component. We employed social network analysis methods to construct datasets linking descriptors of DON respondents with attribute information about 1,164 network members. Statistical analyses (ANOVAs, point biserial correlations, and binomial logistic regression) yielded several findings supporting our hypothesis: (i) DONs' professional networks closely resembled the teams in which they worked daily; (ii) DONs relied on this core network of individuals to provide task support primarily; (iii) DON-nursing home administrator relationships were most important; and (iv) perceptions of support quality and support from nursing home administrators were the strongest predictors of DON intent to stay.

Virtual study groups and online Observed Structured Clinical Examinations practices - enabling trainees to enable themselves.

OBJECTIVES: To explore online study groups as augmentation tools in preparing for the Royal Australian and New Zealand College of Psychiatrists Observed Structured Clinical Examinations (OSCE) for fellowship. METHODS: An online survey of New Zealand trainees was carried out to assess exam preparedness and openness to virtual study groups and results analysed. Relevant material around virtual study groups for fellowship examinations was reviewed and used to inform a pilot virtual study group. Four New Zealand trainees took part in the pilot project, looking at using a virtual platform to augment OSCE preparation. RESULTS: Of the 50 respondents 36% felt adequately prepared for the OSCE. Sixty-four per cent were interested in using a virtual platform to augment their study. Virtual study groups were noted to be especially important for rural trainees, none of whom felt able to form study groups for themselves. The pilot virtual study group was trialled successfully. All four trainees reported the experience as subjectively beneficial to their examination preparation. CONCLUSIONS: Virtual platforms hold promise as an augmentation strategy for exam preparation, especially for rural trainees who are more geographically isolated and less likely to have peers preparing for the same examinations.

Effects of Uncertainty on Perceived and Physiological Stress in Caregivers of Stroke Survivors: A 6-Week Longitudinal Study.

Caregivers' stress following a family member's stroke is likely accentuated by its associated uncertainty. The purpose of the current study was to examine the effect of uncertainty on caregivers' perceived and physiological stress (i.e., salivary cortisol). A prospective, longitudinal observational study was conducted with a convenience sample of 40 caregivers and stroke survivors recruited from acute care settings. Linear mixed models were used. Greater uncertainty was associated with higher perceived stress (p < 0.001), but not with physiological stress (p = 0.32 on waking, p = 0.06 evening), over the first 6 weeks post-stroke. A significant association between uncertainty and evening salivary cortisol level was found at 6 weeks post-stroke (p = 0.009). Recognition of uncertainty early in the caregiving period and targeted interventions may be useful in reducing perceived stress for this group. [Journal of Gerontological Nursing, 43(11), 30-40.].

Effects of a Multicomponent Restraint Reduction Program for Korean Nursing Home Staff.

PURPOSE: Physical restraints are used frequently in Korea, suggesting a growing need for access to programs focused on reduction. The aim of this study was to evaluate the effects of a multicomponent restraint reduction program (MRRP) for nursing staff in Korean nursing homes. DESIGN: A cluster-randomized, single-blind, controlled pretest-posttest design was used. A total of 122 nursing staff (nurses and geriatric care assistants) in two Korean nursing homes participated in this study: 62 in the experimental group (EG) and 60 in the control group (CG). METHODS: Nursing staff in the EG home received the MRRP comprising three educational sessions (two classroom-based and one web-based) and two unit-based consultations. Three instruments were used to measure nursing staff's knowledge, perceptions, and attitudes regarding physical restraints. Data were collected immediately before and after the intervention, and again 1 and 3 months later. FINDINGS: Repeated measures analysis of variance showed significant differences between groups in knowledge (p < .001), perceptions (p < .001), and attitudes (p = .011) over time. These significant improvements in the MRRP group (EG) were sustained over the 3-month period. CONCLUSIONS: The MRRP effectively improved the knowledge, perceptions, and attitudes of nursing home staff about restraint use with older adults. Additional studies are recommended to evaluate effects of its components while using larger samples and rigorous research methods and measurements, and the inclusion of boosters or other supports to sustain change. CLINICAL RELEVANCE: These results provide valuable knowledge regarding a multicomponent intervention for changing nursing home staff attributes that likely influence clinical practice. Elements of the educational content and methods found useful for nursing home staff may also be effective in vocational and continuing education as well as for families of older nursing home residents.

Navigating through the Competency Based Fellowship Program: two trainees' experience of the 2012 program.

OBJECTIVES: This article discusses the real-life experience of two senior registrars who are approaching the end of their training under the 2012 Competency Based Fellowship Program. We have shared some practical tips to assist trainees in completing the Program, with particular emphasis on examination preparation. CONCLUSION: Whilst stressful at times, we believe that going through the Competency Based Fellowship Program has helped us build our knowledge, skills base, and expertise for practising psychiatry as consultants.

Work-life balance and welfare.

OBJECTIVES: An online survey and focus groups were conducted, providing qualitative information on the work-life balance of psychiatrists and trainees in Australasia. METHODS: An invitation to participate in an anonymous online welfare survey was emailed to all the Royal Australian and New Zealand College of Psychiatrists trainees, Fellows, and Affiliates. Following this, nine focus groups were held across Australia and New Zealand. RESULTS: Responses received were thematically analysed. The emergent patterns are presented in this report. CONCLUSIONS: Our research suggests that work-life balance can be subjectively and objectively measured. There are phases of good and bad work-life balance, depending on stage of career and other commitments. Work-life balance may be an indicator of the health of individuals and organisations. Due to its complexity, with intrinsic and extrinsic factors involved, solutions are unlikely to be simple. Further studies are needed to substantiate our findings.

Staff perceptions of barriers to physical restraint-reduction in long-term care: a meta-synthesis.

AIMS AND OBJECTIVES: To critically review the existing qualitative studies to identify, from the perspective of staff, the barriers to physical restraint reduction in long-term geriatric care facilities. BACKGROUND: Despite the adverse physical and psychosocial effects, physical restraints are still used frequently in many geriatric long-term care facilities around the world. There is, however, no study that synthesises the existing qualitative literature regarding the barriers to the restraint reduction from the perspective of facility staff. DESIGN/METHODS: The metastudy research process guided this qualitative synthesis. Five electronic databases were searched, and ten studies were included in this metastudy. RESULTS: Five themes were identified through metasynthesis of the findings: concern about and responsibility for safety, unclear and inconsistent definitions of restraint and restraint-free care, difficulties in the transition from acceptance to removal, noninvolvement in decision-making to remove restraint and insufficient resources and education. CONCLUSION: A concept analysis of physical restraint is sorely needed, and future studies should explore the prevalence of restraint, the effects of education for staff and family on restraint reduction, and success stories related to restraint-free care. More research is needed regarding the restraint reduction effectiveness and cost issues. RELEVANCE TO CLINICAL PRACTICE: Physical restraints, commonly used in many geriatric long-term care facilities, result in many negative effects and ethical issues. To achieve success in reducing physical restraint use, governmental policies and long-term care institutions should underpin staff efforts with legal, educational and practical support.

Caregiving Immediately After Stroke: A Study of Uncertainty in Caregivers of Older Adults.

BACKGROUND: Caregivers of stroke survivors experience high rates of mental and physical morbidity. Stroke has sudden onset, and the outcome is not immediately known. Uncertainties surrounding the new caregiving role may not only necessitate major changes in the lives of family caregivers but also contribute to negative health outcomes for the caregiver. PURPOSE: The purposes of this study were to describe caregiver uncertainty across the early weeks after a family member's stroke and to explore characteristics of caregivers and stroke survivors associated with that uncertainty. METHODS: A prospective, longitudinal exploratory observational study was conducted with a convenience sample of 40 caregivers and older adult (≥65 years) stroke survivors recruited from urban acute care settings in the mid-Atlantic region. Caregivers were enrolled by 2 weeks poststroke (T1) and revisited 4 weeks later (T2). Uncertainty was measured usingthe Mishel Uncertainty in Illness Scale for Family Members. An unadjusted linear mixed model was computed to examine significant associations between each caregiver or stroke survivor characteristic and repeated measures of uncertainty. RESULTS: Uncertainty at T1 (83.73 ± 23.47) was higher than reported in other caregiver populations and remained high 6 weeks poststroke (T2: 85.23 ± 23.94). Each of the following characteristics was independently associated with greater caregiver uncertainty: caregivers' older age (p = .019), being a spouse (p = .01), higher stress (p < .001), more depressive symptoms (p = .001), more comorbidities (p = .035), and poorer coping capacity (p = .002) and stroke survivors' recurrent stroke (p = .034), poorer functional status (p = .009), and insurance type (p = .008). CONCLUSIONS: Caregivers experienced persistently high uncertainty during the first 6 weeks poststroke. Better understanding of uncertainty, its associated characteristics, and its outcomes may help clinicians identify caregivers at highest risk who may benefit from targeted interventions.

Severe motor and vocal tics controlled with Sativex®.

OBJECTIVES: A single case report on cannabinoid treatment for treatment-resistant Tourette syndrome (TS). METHOD: Our subject received 10.8 mg Tetrahydocannabinol and 10 mg cannabidiol daily, in the form of two oro-mucosal sprays of 'Sativex®', twice daily. Assessment was pre-treatment and at week one, two, and four during treatment. He completed the Yale Global Tic Severity Scale as a subjective measure, and was videoed at each stage. The videos were objectively rated by two assessors, blind to the stage of treatment, using the Original Rush Videotape Rating Scale. RESULTS: Both subjective and objective measures demonstrated marked improvement in the frequency and severity of motor and vocal tics post-treatment. There was good interrater reliability of results. CONCLUSIONS: Our results support previous research suggesting that cannabinoids are a safe and effective treatment for TS and should be considered in treatment-resistant cases. Further studies are needed to substantiate our findings.

Apathy in Frontotemporal Degeneration: Neuroanatomical Evidence of Impaired Goal-directed Behavior.

BACKGROUND: Apathy, the major manifestation of impaired goal-directed behavior (GDB), is the most common neuropsychiatric syndrome associated with behavioral variant frontotemporal degeneration (bvFTD). The behavioral and biological mechanisms of apathy, however, are not well understood. We hypothesized that GDB has multiple components-including at least initiation, planning and motivation-and that GDB is supported by a network of multiple frontal brain regions. In this study, we examined this hypothesis by evaluating the selective breakdown of GDB in bvFTD, and relating these deficits to gray matter (GM) atrophy and white matter (WM) integrity. METHODS: Eighteen apathetic bvFTD participants and 17 healthy controls completed the Philadelphia Apathy Computerized Test (PACT). This test quantifies each of three components of GDB hypothesized to contribute to apathy. We then used regression analyses to relate PACT scores to GM atrophy and reduced white matter (WM) fractional anisotropy (FA) in bvFTD. RESULTS: Compared to controls, bvFTD participants demonstrated significant impairments in each of the three hypothesized components of GDB that contribute to apathy. Regression analyses related each component to disease in specific GM structures and associated WM tracts. Poor initiation thus was related to GM atrophy in anterior cingulate and reduced FA in the cingulum. Planning impairment was related to GM atrophy in dorsolateral prefrontal cortex and reduced FA in superior longitudinal fasciculus. Poor motivation was related to GM atrophy in orbitofrontal cortex (OFC) and reduced FA in uncinate fasciculus (UNC). CONCLUSIONS: bvFTD patients have difficulty with initiation, planning and motivation components of GDB. These findings are consistent with the hypotheses that GDB encompasses at least three processes, that these are supported by a large-scale neural network within specific portions of the frontal lobe, and that degradation of any one of these prefrontal regions in bvFTD may contribute to apathy.

Addressing gaps in mental health needs of diverse, at-risk, underserved, and disenfranchised populations: a call for nursing action.

Psychiatric nurses have an essential role in meeting the mental health needs of diverse, at-risk, underserved, and disenfranchised populations across the lifespan. This paper summarizes the needs of individuals especially at-risk for mental health disorders, acknowledging that such vulnerability is contextual, age-specific, and influenced by biological, behavioral, socio-demographic and cultural factors. With its longstanding commitment to cultural sensitivity and social justice, its pivotal role in healthcare, and its broad educational base, psychiatric nursing is well-positioned for leadership in addressing the gaps in mental health prevention and treatment services for vulnerable and underserved populations. This paper describes these issues, presents psychiatric nursing exemplars that address the problems, and makes strong recommendations to psychiatric nurse leaders, policy makers and mental health advocates to help achieve change.

Concept Analysis of Burden in Caregivers of Stroke Survivors During the Early Poststroke Period.

It is important to understand burden in caregivers of stroke survivors during the early poststroke period if we are to prevent or decrease the longer-term experience of caregiver burden and its consequences. This article reports a concept analysis of burden in caregivers of stroke survivors during the early poststroke period. A literature review using MEDLINE, PubMed, CINAHL, PsycINFO, and ISI Web of Knowledge databases (1960-2014) identified 32 relevant articles published from 1993 to 2013. Rodgers's evolutionary method of concept analysis was used. Three attributes--objective and subjective aspects, time spent caring for the stroke survivor, and uncertainty about the future for the stroke survivor and caregiver--were identified. Multiple definitions of caregiver burden have been used. In the early poststroke period, burden appears closely interconnected with other factors, some of which may be modifiable.

Differentiating subtypes of apathy to improve person-centered care in frontotemporal degeneration.

Apathy, a reduction in goal-directed behavior (GDB), affects 90% of individuals with behavioral variant frontotemporal degeneration, which is a common cause of early onset neurodegenerative disease. The cognitive and neural impairments associated with apathy make it difficult to initiate, plan, and self-motivate activities toward a specific goal, such as dressing or bathing. These impairments are associated with significant decline in functional ability, caregiver burden, and increased cost of care due to early institutionalization. The current article reviews the evidence suggesting that apathy arises from the interruption of one or any combination of three GDB processes: initiation, planning, and motivation. From this perspective, three subtypes of apathy related to dysfunction at the level of GDB and the corresponding neuroanatomy are explored. Further research is required to confirm and measure these subtypes of apathy for use in clinical and research settings. A more precise classification of apathy by subtype will allow implementation of the most appropriate person-centered, individualized therapy.

Caring for loved ones with frontotemporal degeneration: the lived experiences of spouses.

There is an abundant literature about the experience of caregiving for a spouse living with Alzheimer's disease (AD), but there are very few qualitative studies about caregiving for persons living with Frontotemporal Degeneration (FTD). FTD causes a change in personality and affected persons may lose the ability to adhere to social norms. Thus, the emotional loss caregivers experience is often confounded by anger in response to embarrassing and socially inappropriate behaviors. In this paper, we offer a glimpse of this lived experience through the voices of two spouses whom we interviewed, each with experience caring for persons living with FTD. We suggest that FTD caregivers experience a loss of emotional attachment to their spouse because of their partner's behavioral symptoms. This loss gives rise to feelings of isolation and anger as caregivers assume new roles and reimagine their future. The findings from these interviews illuminate the need for more research and greater attention and support for FTD caregivers early in the disease trajectory.

Screening for delirium using family caregivers: convergent validity of the Family Confusion Assessment Method and interviewer-rated Confusion Assessment Method.

OBJECTIVES: To explore agreement between the Family Confusion Assessment Method (FAM-CAM) for delirium identification and interviewer-rated CAM delirium ratings. DESIGN: Exploratory analysis of agreement. SETTING: Community. PARTICIPANTS: Fifty-two family caregivers and 52 elderly adults with preexisting impairment according to standardized cognitive testing. MEASUREMENTS: The interviewer-rating for delirium was determined by fulfillment of the CAM algorithm RESULTS: The total sample included 52 paired CAM:FAM-CAM assessments completed across 52 dyads of elderly adults with preexisting cognitive impairment and family caregivers. The point prevalence of delirium was 13% (7/52). Characteristics did not differ significantly between the groups with and without delirium. The FAM-CAM questions that mapped directly to the original four-item CAM algorithm had the best overall agreement with the interviewer-rated CAM (kappa = 0.85, 95% confidence interval (CI) = 0.65-1.0), sensitivity of 88% (95% CI = 47-99%), and specificity of 98% (95% CI = 86-100%). CONCLUSION: The FAM-CAM is a sensitive screening tool for detection of delirium in elderly adults with cognitive impairment using family caregivers, with relevance for research and clinical practice.