Improving the ability of mental health nurses to give second opinion in Judicial Reviews: an evaluation study.

In New Zealand, concern has been expressed regarding the variable quality of second opinions given by health professionals assisting judicial decisions on the use of compulsory assessment and treatment under mental health legislation. This second opinion is mostly given by registered mental health nurses. An innovative education programme based on experiential learning and adult learning principles was developed to assist health professionals to effectively undertake this role. A mixed method pre-post test intervention research design was developed to evaluate the effectiveness of the programme in assisting health professionals to feel more competent in undertaking the role. Data from the participants (n= 112) was subjected to descriptive statistical analysis and a thematic analysis of open-ended questions. The findings suggested gains in all competencies following the education programme, although there was room for further improvement. These changes were sustained over time at the next occasion when the health professionals undertook the role. There is a need to nationally disseminate such educational innovations to assist more mental health nurses to maximize their input into judicial decisions, which have a marked impact on the lives of those service users involved.

The role of second health professionals under New Zealand mental health legislation.

The development of generic statutory roles in mental health care has been the subject of discussion by New Zealand nurses for the past decade. One such role is that of second health professional in judicial reviews of civil commitment. Issues identified by New Zealand nurses have also been raised in England, where it seems that nurses are likely to assume the role of Approved Mental Health Worker under English mental health law. A survey of mental health nurses found that few had received any preparation for the role of second health professional and 45% did not feel adequately prepared for the role. Some of these issues are reflected in a New Zealand inquiry which resulted in the Ministry of Health developing a written report form for second health professionals. However, the form has the potential to reduce the mental health nursing role to a narrow legal role. Statutory roles such as that of second health professional challenge mental health nurses to critically reflect on the conceptual and ethical basis of their practice. While traditional concepts such as therapeutic relationships and advocacy need to be reviewed in light of these changes, nurses need to be vigilant in articulating the moral and clinical basis of their roles. The development of guidelines for he second health professional role is suggested as a way of supporting clinical practice in this area.

World without borders: integrating clinical perspectives into the coronial jurisdiction in Victoria, Australia.

A professional world without borders would allow for more appropriate collaboration between the Coroner's office and the healthcare sector in their endeavours to improve patient safety. In Victoria (Australia), the Clinical Liaison Service draws on the distinct experiences and expertise of medical, nursing and research personnel to evaluate clinical evidence for the investigation of healthcare deaths reported to the State Coroner's Office. This approach allows for greater intersectoral collaboration between the Coroner's office and healthcare sector than a traditional English-style coronial system that relies on the expertise of coroners, forensic pathologists and police officers to investigate unexpected deaths. Encouraging collaboration between these two sectors may have averted or at least mitigated the atrocities caused by Harold Shipman or the events at Bristol's Royal Infirmary. This paper describes the work processes employed by the Clinical Liaison Service (CLS) to investigate healthcare deaths in a coronial setting. To describe how this work has fostered the advancement of patient care.

Renal tubular proteinuria in patients with irritable bowel syndrome.

OBJECTIVE: Irritable bowel syndrome (IBS) is a common condition that is poorly understood. We have previously demonstrated tubular protinuria in patients with inflammatory bowel disease. This study examined whether tubular proteinuria was a feature of IBS. METHODS: Eighty control subjects (male:female, 28:52; age range 20-65 years) and 21 patients with IBS (male:female, 9:12; age range 16-64 years) (not significant) were recruited. Patients with known renal disease, hypertension, diabetes or microbiological evidence of urinary infection were excluded. The IBS patients all fulfilled the ROME II criteria. None had preceding gastroenteritis. Urinary alpha1-microglobulin (alpha1-M) was measured in a second-voided morning urine sample and corrected for urinary concentration by measurement of creatine. Blood samples were analysed for haematochemical indices including C-reactive protein. Statistical analysis was by unpaired t test. RESULTS: None of the IBS patients were reclassified with inflammatory bowel disease over a 5-year follow up period. All had normal haematochemical parameters. Mean +/- standard deviation urinary alpha1-M concentrations were significantly higher in IBS patients than controls (IBS patients, 1.17 +/- 0.65 mg/mmol; controls, 0.75 +/- 0.36 mg/mmol; P < 0.01) and exceeded 1.5 mg/mmol (the upper reference limit) in seven patients. There was no difference in urinary alpha1-M concentrations in the diarrhoea-predominant and constipation-predominant groups (mean +/- standard deviation, 1.342 +/- 0.65 versus 0.76 +/- 0.48 mg/mmol; P = 0.062). CONCLUSIONS: Urinary alpha1-M concentration is commonly increased in IBS, suggesting the presence of renal proximal tubular injury.

Coercion in mental healthcare: the principle of least coercive care.

Coercive practices are relatively common in mental healthcare, but coercion is ethically problematic because it involves acting against an individual's autonomy. However, coercion is often poorly defined in mental health literature, resulting in problems in considering coercion from an ethical perspective. This paper challenges the traditional paternalistic justification for coercive practices in mental healthcare, and argues that the failure to make a conceptual distinction between what counts as coercive practice and what justifies coercive practice results in instances of unjustified use of coercion. It also results in the failure to recognize other justifications for coercive practice. We propose a broad definition of coercion that recognizes the prevalence of coercion in mental healthcare. In particular, we wish to recognize the potential for persuasion and manipulation of clients' wishes to be coercive. We argue that there should be a prima facie ban on coercion in mental healthcare, and that the use of coercive practices needs to be justified in the specific circumstances of each case. The presupposition that mental illness involves limited autonomy cannot be taken to justify use of coercion. We outline a principle of least coercive intervention that we think has the potential to lessen the prevalence and extent of coercion in mental healthcare.

Unearthing the conflicts between carer and custodian: implications of participation in Section 16 hearings under the Mental Health (Compulsory Assessment and Treatment) Act (1992).

Mental health nursing occurs within a legal and ethical framework that presents conflicts between a paternalistic custodial role and an ethical commitment to autonomy. This paper considers the ethical conflict for nurses posed by acting as second health professional at judicial reviews under Section 16 of the Mental Health (Compulsory Treatment and Assessment) Act. Issues of advocacy and paternalism are discussed in light of the conflict between therapeutic and legislated roles. Strategies aimed at protecting the therapeutic relationship are outlined as a response to the current lack of guidelines in this area. Participation in legal processes of committal requires that nurses reflect carefully and critically on the ethical issues raised.

Temporal variation in endotoxin-induced vascular hyporeactivity in a rat mesenteric artery organ culture model.

Endotoxin-induced vascular hyporeactivity to phenylephrine (PE) is well described in rodent aorta, but has not been investigated in smaller vessels in vitro. Segments of rat superior mesenteric artery were incubated in culture medium with or without foetal bovine serum (10%) for 6, 20 or 46 h in the presence or absence of bacterial lipopolysaccharide (LPS; 1 - 100 microg ml(-1)). Contractions to PE were measured with or without nitric oxide synthase (NOS) inhibitors: L-NAME (300 microM), aminoguanidine (AMG; 400 microM) 1400W (10 microM) and GW273629 (10 microM); the guanylyl cyclase inhibitor, ODQ (3 microM); the COX-2 inhibitor, NS-398 (10 microM). Contractile responses to the thromboxane A2 mimetic, U46619 were also assessed. In the presence of serum, LPS induced hyporeactivity at all time points. In its absence, hyporeactivity only occurred at 6 and 20 h. L-NAME and AMG fully reversed hyporeactivity at 6 h, whereas they were only partially effective at 20 h and not at all at 46 h. In contrast partial reversal of peak contraction was observed with 1400W (62% at 46 h), GW273629 (57% at 46 h) and ODQ (75% at 46 h). COX-2 inhibition produced no reversal. In contrast to PE, contractions to U46619 were substantially less affected by LPS. We describe a well-characterized reproducible model of LPS-induced hyporeactivity, which is largely mediated by the NO-cyclic GMP-dependent pathway. Importantly, long-term (2-day) production of NO via iNOS is demonstrated. Moreover, conventional doses of L-NAME and AMG became increasingly ineffective over time. Thus, the choice of inhibitor merits careful consideration in long-term models.

The therapeutic relationship: historical development and contemporary significance.

The therapeutic relationship is a concept held by many to be fundamental to the identity of mental health nurses. While the therapeutic relationship was given formal expression in nursing theory in the middle of the last century, its origins can be traced to attendants' interpersonal practices in the asylum era. The dominance of medical understandings of mental distress, and the working-class status of asylum attendants, prevented the development of an account of mental health nursing based on attendants' relationships with asylum inmates. It was left to Peplau and other nursing theorists to describe mental health nursing as a therapeutic relationship in the 1940s and later. Some distinctive features of colonial life in New Zealand suggest that the ideal of the attendant as the embodiment of bourgeoisie values seems particularly unlikely to have been realized in the New Zealand context. However, New Zealand literature from the 20th century shows that the therapeutic relationship, as part of a general development of a therapeutic discourse, came to assume a central place in conceptualizations of mental health nursing. While the therapeutic relationship is not by itself a sufficient basis for professional continuity, it continues to play a fundamental role in mental health nurses' professional identity. The way in which the therapeutic relationship is articulated in the future will determine the meaning of the therapeutic relationship for future generations of mental health nurses.

Negotiating the relationship: mental health nurses' perceptions of their practice.

This exploratory descriptive study used focus groups to investigate experienced mental health nurses' perceptions of expertise in relation to their practice. Two focus group discussions were conducted, one comprising four nurses working in inpatient care and the other with five nurses working in community care. The nurse-patient relationship was the central theme for both groups. Three sub-themes were identified and are discussed. They are involvement, individualizing care, and minimising visibility. The significance of these themes for the articulation of mental health nursing practice is discussed.

Relationships between NADPH diaphorase staining and neuronal, endothelial, and inducible nitric oxide synthase and cytochrome P450 reductase immunoreactivities in guinea-pig tissues.

The presence of NADPH diaphorase staining was compared with the immunohistochemical localization of four NADPH-dependent enzymes-neuronal (type I), inducible (type II), and endothelial (type III) nitric oxide synthase (NOS) and cytochrome P450 reductase. Cell types that were immunoreactive for the NADPH-dependent enzymes were also stained for NADPH diaphorase, suggesting that endothelial and neuronal NOS and cytochrome P450 reductase all show NADPH diaphorase activity in formaldehyde-fixed tissue. However, in some tissues, the presence of NADPH diaphorase staining did not coincide with the presence of any of the NADPH-dependent enzymes we examined. In vascular endothelial cells, the punctate pattern of staining observed with NADPH diaphorase histochemistry was identical to that seen following immunohistochemistry using antibodies to endothelial NOS. In enteric and pancreatic neurons and in skeletal muscle, the presence of NADPH diaphorase staining correlated with the presence of neuronal NOS. In the liver, sebaceous glands of the skin, ciliated epithelium, and a subpopulation of the cells in the subserosal glands of the trachea, zona glomerulosa of the adrenal cortex, and epithelial cells of the lacrimal and salivary glands, the presence of NADPH diaphorase staining coincided with the presence of cytochrome P450 reductase immunoreactivity. In epithelial cells of the renal tubules and zona fasciculata and zona reticularis of the adrenal cortex, NADPH diaphorase staining was observed that did not coincide with the presence of any of the enzymes. Inducible NOS was not observed in any tissue. Thus, while tissues that demonstrate immunoreactivity for neuronal and endothelial NOS also stain positively for NADPH diaphorase activity, the presence of NADPH diaphorase staining does not reliably or specifically indicate the presence of one or more NOS isoforms.

Nitric oxide synthase is localized predominantly in the Golgi apparatus and cytoplasmic vesicles of vascular endothelial cells.

The localization of nitric oxide synthase (NOS) in vascular endothelial cells of submucosal blood vessels from the guinea-pig ileum was examined using NADPH diaphorase histochemistry at the light microscopic level, and endothelial NOS immunohistochemistry at the light and electron microscopic level. The pattern of staining observed following NADPH diaphorase histochemistry and endothelial NOS immunohistochemistry was identical. Endothelial cells of the arterioles, capillaries and venules showed small patches of intense, perinuclear staining. Under the electron microscope, endothelial NOS immunoreactivity was found predominantly in association with the Golgi apparatus and with the membranes of some vesicles. Small regions of the plasma membrane and the rough endoplasmic reticulum also showed some immunoreactivity. The presence of NOS in the Golgi apparatus and in vesicles raises the possibility that NOS may be exteriorized by endothelial cells, and hence that nitric oxide is synthesized extracellularly.

Temperature dependency of the frequency and level of a spontaneous otoacoustic emission during fever.

Using a method of heterodyne mixing with display of beats on a chart recorder, measurements were made of the frequency and level of a spontaneous otoacoustic emission in a human subject on 17 occasions during a period of 13 consecutive days. Temperature measurement was obtained with a thermometer measuring infra-red radiation from the ear-drum, indicative of body core temperature. In the latter half of this period there was variation of body set point temperature due to fever, and it was found that there was clear evidence of inverse relationship between temperature and both the frequency and level of the emission. The occurrence of fever was due to simple urinary tract infection and was considered to be without ototoxic implication; there was no associated worsening of pure tone threshold nor change in measurements of middle ear function.